Waitlist | Mended Wing Counseling, LLC

Name*

Name of client

First Last

Name

Name of person filling out form (if different than name of client)

First Last

Phone*

Enter the number you would like to be contacted at

Email*

Enter the email address you would like to be contacted at

Preferred method of contact*

How would you prefer we reach out to you?

What is this waitlist request regarding?*

Please select what it is you are requesting to be placed on the waitlist for

Individual Therapy (Please indicate which clinician in the next question)
Group Therapy (Please indicate which group in the below text box; DBT, parental support, other)
Hold Me Tight Weekend
Supervision

Whom are you requesting for waitlist?

Please select who it is you are requesting to be placed on the waitlist for

Waitlist Info*

Please indicate more information about the waitlist request

Form of payment*

Date*

Consent*

I agree to being contacted in the above selected format.