New Client Appointment Request Form

First Name

Last Name

Email Address

Phone Number

Date of Birth for Individual Seeking Counseling:

Scheduling Availability (Please include any daytime availability if applicable):

Briefly, what brings you to counseling? For family therapy, please include ages of family members:

For minor clients, does your child have a parent that lives outside of your home? If so, please share custody information and if both parents consent to starting therapy:

Your information will be encrypted.