Request for Counseling Services*

Please correct the errors described below.

*This form may only be used to request counseling services. Requests for neuropsychological evaluations require a formal physician's referral to be faxed to our office by your physician. Requests for evaluations sent via this form will not be processed.

Patient Details

PLEASE NOTE: We are only able to see patients for counseling services who are aged 17 and up.

Guardianship Information

Contact Information

Add Additional Phone Number(s)

Emergency Contact (please list at least one person who we can contact in case of an emergency)

Add Emergency Contact

Financial/Insurance Information

Add Insurance Plan

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    Personal Information (Optional - please feel free to skip this section if you don't feel comfortable answering these questions)

    Family Information (please list other members of your household who are living with you)

    Add Household Member

    Providers (please list your physician and/or any other medical or behavioral health providers you see)

    Add Provider

    Previous Services


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      Add Medication

      Medical History

      Other Information

      Reason for Consultation

      Thank you for taking the time to provide us with this information. These details assist us helping to match you up with the therapist who has the most experience working with the challenges that you are facing. Once we process this information, a staff member will reach out to you to set up an appointment with your assigned therapist.

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