New Client Appointment Request - Secure Portal

By entering your full name, email address, insurance information and phone number below, you are providing personal information that will be used by Master Peace Wellness & Consulting, PLLC for the sole purpose of responding to your request. We will only use this information to contact you in order to schedule your appointment.

Please correct the errors described below.

Client Info

XX/XX/XXXX
Please provide gender filed with insurance.

Partner Info (This section is for Couples Counseling only)

XX/XX/XXXX

Insurance Info

Your address on file with insurance provider.

Primary Insured Information

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

EAP Information - If using EAP, please complete in entirety.

For EAP appointment request only
Start and End dates needed

Upload Insurance card/EAP authorization information

    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 MPW Team.

    Your information will be encrypted.

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