Outpatient Youth & Family Counseling Appointment Request

Please complete the form below if you’d like to schedule a counseling appointment with one of our outpatient therapists. You will be contacted by our scheduler shortly after your information is received. Our outpatient counseling services is for both female and male clients of all ages. Please see our specialties and locations.

If you have any questions concerning our services that you’d like answered prior to scheduling your appointment, please e-mail us.

Bold fields are required.

Your Information

Your Name*

Your Email*

Client Information

First Name*

Last Name*

Middle Initial

Birth Date(mm-dd-yyyy)*

Gender*

Marital Status*

Address

City

State

Zip

Phone

Cell Phone

Religion

Spouse/Parent(s) or Legal Guardians (If client is under 18)

Name

Address

Birth Date(mm-dd-yyyy)

Relationship

Name

Address

Birth Date(mm-dd-yyyy)

Relationship

Employer (if client is a minor list parent/guardian employer)

Employer

Employer

Family Income

Children (please list all children of the client and/or all children living in the home with the client)

Name

Age

DOB(mm-dd-yyyy)

Gender

Live with mom, dad, both, other

Name

Age

DOB(mm-dd-yyyy)

Gender

Live with mom, dad, both, other

Name

Age

DOB(mm-dd-yyyy)

Gender

Live with mom, dad, both, other

Name

Age

DOB(mm-dd-yyyy)

Gender

Live with mom, dad, both, other

Name

Age

DOB(mm-dd-yyyy)

Gender

Live with mom, dad, both, other

Name

Age

DOB(mm-dd-yyyy)

Gender

Live with mom, dad, both, other

Insurance Information

Plan Name

Company Name

Address

City

State

Zip

Phone

Member ID Number

Policy Number

Group Number

Policy Holder Information

 Check here if same as Client Information

First Name

Last Name

Middle Initial

Birth Date(mm-dd-yyyy)

Address

City

State

Zip

Phone

Relationship to client

Employer Name

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