Counseling Inquiry
Complete the brief form below and someone on our behavioral health team will reach out to you. This form is HIPAA compliant to protect your information.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred method of communication:
*
Phone call
Text message
Email
Are you interested in in-person therapy appointments, at our office on Thompson Lane, or telehealth/video appointments?
In Person
Telehealth
Open to either
Briefly describe what led you to seek therapy or what you would like to work on (optional).
Are you interested in participating in group therapy?
*
Yes
No
How did you hear about our counseling services?
*
Thank you! We currently have a waitlist for counseling - a therapist will contact you to schedule as soon as possible.
Please note: this form is not monitored 24/7. If you are experiencing a mental health emergency, please call 988 or go to your nearest hospital emergency room.
Submit
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