Initial Contact Form

These questions are asked to help clarify if your needs and our services would likely be a good fit. If you would prefer to answer these questions over the phone and NOT electronically, please contact us using the number on our website.

Please correct the errors described below.

First name

Last name

Pronouns

Date of Birth

If you are a parent/guardian seeking counseling for a child (under 18), please use the child's date of birth

Where do you typically live? (City, State)

Email address

Phone number

Do we have permission to email you?

Yes No

Do we have permission to leave you a voicemail?

Yes No

Which of the following are you hoping for?

In-person appointments Telehealth video appointments Either way

Which of the following are you hoping for?

Individual counseling Couples counseling Family counseling

Do you hope to use health insurance to help pay for counseling? If so, what’s the name of your insurance company?

Note: Information on our Fees & Insurance can be found on our website at: https://tpccounseling.org/fees-insurance. Please feel free to let us know of any questions.

If you had to summarize in just around 1-2 sentences your main reason(s) for seeking counseling at this time, what would you say?

Is there anything else you'd like us to know at this point?

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