Type of Counseling(Required) Adult Individual Child Couple Family Other Client's Name(Required) First Last Your NameIf you are filling out this form on behalf of the client. First Last Client's Date of Birth(Required) MM slash DD slash YYYY Phone Number(Required)Email(Required) Street Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Partner's Name(Required) First Last Partner's Date of Birth(Required) MM slash DD slash YYYY Partner's Phone Number(Required)Partner's Email(Required) How will you be paying for services?(Required) Insurance Insurance (Medicaid) Self-Pay Other Type of Insurance(Required)Member ID Number/DoD Benefits Number(Required)Policyholder Name(Required) First Last Policyholder Date of Birth(Required) MM slash DD slash YYYY Policyholder Relation to ClientIf you are using Tricare: Please indicate if you have a preference(Required)Rates differ depending on the counselor you are matched with; We offer Intern services for $30 a session, Associates for $60, or Fully-licensed Professionals for $120. Intern Associate Fully Licensed Professional No Preference Other Please provide more information below(Required)Please provide a brief reason for seeking counseling(Required)Day Preference for Scheduling Monday Tuesday Wednesday Thursday Friday Saturday Sunday No Preference Time Preference for Scheduling Morning Afternoon Evening No Preference Let us know which option works best for you to schedule at this timeOur providers are accepting new clients via online Telehealth as well as for In-person appointments. Telehealth In-Person No Preference Which location would you prefer to be seen at?Not all therapists work at all offices, preferred location is not guaranteed. Pooler Rincon Savannah How did you find us?Please indicate if there is a referral.Anything else you feel we should know regarding scheduling?Anything else you feel we should know regarding scheduling?
