Counseling Appointment Request

Email address:

Please provide a brief description of your counseling needs:

How did you hear about our practice?

First and Last name of person completing this form:

Phone number of person completing this form:

Client first and last name (if different from person completing this form):

Client date of birth:

Photo of FRONT of your insurance card If you are unable to upload it, please email it to carolina-counseling@hushmail.com

Add file

Please upload a file

Photo of BACK of your insurance card: If you are unable to upload it, please email to carolina-counseling@hushmail.com

Add file

Please upload a file

Insurance policy holder name (First and Last):

Insurance Member ID

Insurance Group Number

Your information will be encrypted.