New form

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Client Information


Partner's Info (This section is for Couples Counseling Only)



Insurance Information

Your address on file with insurance provider

Primary Insured Information

Address, City, State, Zip Code. On file with insurance company

EAP Appointment Request

For EAP appointment request only
    Please upload a file
    Please note your desired therapist may not have availability, but we will do our best to match you with another skilled therapist of the GLC Team.

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