Counseling Appointment Request

Email address

Please provide a brief description of your counseling needs:

How did you hear about our practice?

Is CPS or the court system (including custody cases) involved with you or your family? If yes, please provide a brief summary.

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

Add file

Please upload a file

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

Add file

Please upload a file

Insurance Member ID

Insurance Group Number

Insurance policy holder name (First and Last):

Policy holder date of birth:

Policy holder phone number:

Policy holder address (street address, city, state, zip):

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