Counseling Interest Form

Date

Name

Please type full name, as noted on Social Security Card

Gender

Date of Birth

Home Address

Email address

Home Number

Cell Number

What is your Social Security #?

*Needed to Verify Insurance and Coverage

If you do not have NC Driver's License and/or Insurance Card, write "N/A" on paper and upload picture as an alternative.

Upload Insurance Card If you do not have insurance, take a picture of a hand written note stating you have no insurance.

Add file

Please upload a file

Upload NC Drivers' License If you are not a North Carolina Resident, please email Mrs. Tanielle L.A. Brown immediately. If you are under the age of 18, please include your parent's driver's license.

Add file

Please upload a file

Upload Headshot Selfie Please take a selfie headshot against a wall with nothing behind you.

Add file

Please upload a file

Employee Assistance Program (EAP) Referral

Yes

Authorization#

**Request from EAP or HR

Name of EAP

Open Path Referral

Yes

Please share "how" you were referred to Eclectic Therapeutic Connections?

Please check the counseling services you are seeking:

Individual Counseling

Couple Counseling

Family Counseling

Support Group

Who Referred you to Eclectic Therapeutic Connections, PLLC?

If you were not referred , how did you learn about Eclectic Therapeutic Connections, PLLC?

What is the presenting problem that motivated you to seek therapy?

Who is your cell phone carrier?

*Cell Phone Service / Needed to troubleshoot connection w/ virtual sessions

Your information will be encrypted.