Secure Contact Form

Thank you for reaching out!

This is a secure inquiry form for The Brooke Center for Counseling & Wellness, LLC. Once we receive your form, we will reach out via email within two business days to discuss next steps.

First name

Last name

Email address

Phone number

City & State of Permanent Residence

i.e. Dallas, Texas etc.

Date of Birth

Do you give permission for The Brooke Center to contact you via phone or email? If not, please know that it will increase the length of time to begin services.

Yes No

Please briefly describe what you are seeking services for?

How did you hear about The Brooke Center?

Do you have healthcare insurance? We are required by law to ask if you have insurance. The Brooke Center for Counseling and Wellness is a fee-for-service, private practice and does not currently particpate in insurance plans.

Yes No

Are you eligible for Medicare Benefits? We are required by law to ask if you qualify for medicare. The Brooke Center for Counseling and Wellness is a fee-for-service, private practice and does not currently participate in filing with/for medicare.

Yes No

Verification of Information I acknowledge and grant permission to be contacted at the information listed about from the The Brooke Center for Counseling and Wellness, LLC. I agree that I have completed this form for myself or a minor that I am guardian of. By checking 'Yes', it denotes my signature and validity to the above form.

Yes No

The Brooke Center for Counseling and Wellness uses Hushmail as our confidential, HIPPA compliant email service. You will need to login to a secure portal to view and respond to the email. This can easily connect to your present email address. Thank you!

Your information will be encrypted.