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
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?
*
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
Should be Empty: