Request for General Information OR Consultation Request FOR: {Potential Client OR Professional/Clinical Consultation}

Emergency Assistance

If this is an emergency, call:

Client~Individual~Customer Information

First name

Last name

Email address (Required)

Phone number

Client DOB (Date of Birth)

Please enter the client complete date of birth.

I'm new here

I'm already a client

Client Insurance/ Payment Method

Insurance

Self-Pay

Other

1.) NAME/TYPE OF INSURANCE/PAYMENT METHOD (2.) HEALTH INSURANCE CARD NUMBER (INCLUDE ALL INSURANCE CARDS)

(Ex.#1) Insurance- Absolute Total Care-ZDV0000000 (Ex.#2) / Self-Pay- Visa/Master Card (DO NOT type credit card #, LIST the Type)

Responsible Party Information (Parent/Legal Guardian/Self)

First Name

Last Name

Email Address (Required)

Phone Number

Parent DOB (Date of Birth)

Please enter the complete date of birth of the parent/responsible party.

Your Relationship to Client

Ex. Parent, Legal Guardian, Self

Date & Time (Preferred)

Date

Availability Varies. Send Request and we will let you know if this date and time works.

Time

Appointments for general information requests and potential new client consultations are no longer than 5 minutes. Professional Consultation times range from 1-60 minutes.

About Your Appointment Request

Additional Information about your General Information or Consultation Request:

If there's anything else that you would like us to know prior to your appointment, please include it here.

Your information will be encrypted.

Request for General Information OR Consultation Request FOR: {Potential Client OR Professional/Clinical Consultation}

Emergency Assistance

Client~Individual~Customer Information

Responsible Party Information (Parent/Legal Guardian/Self)

Date & Time (Preferred)

About Your Appointment Request

Emergency Assistance

TRiY Counseling Services, LLC