Appt. Request -Couple

*Please choose who will be the identified client / whose insurance will be billed. Provide the identified client's information in the top section. The second person's information will be entered in the bottom section. Thank you!

Email:(*)

This is not a valid email address.

Mobile Phone:(*)

Invalid phone number. Please enter a valid phone number. Thank you.

First Name(*)

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Last Name:(*)

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DOB:(*)

Gender

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Street Address:

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City:

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State:

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Zip Code:

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Health Insurance(*)

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Policy Number:(*)

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Subscriber:(*)

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Copay Amount:(*)

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*Please provide non-identified client's information below, Thank You!

Email(*)

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Phone(*)

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First Name (*)

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Last Name(*)

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DOB(*)

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Gender

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Times:(*)

Detailed Availability:

0/1000

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Briefly describe why you are seeking counseling at this time. (*)

0/1000

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Telehealth / Video Sessions?(*)

Only interested in telehealth sessions.

I prefer telehealth sessions.

I prefer in-person sessions.

Only interested in in-person sessions.

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CAPTCHA (lower case letters only)(*)

CAPTCHA (lower case letters only)

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Appointment Request Form -Couple

*Please choose who will be the identified client / whose insurance will be billed. Provide the identified client's information in the top section. The second person's information will be entered in the bottom section. Thank you!

*Please provide non-identified client's information below, Thank You!