Appointment Request

Please complete the following registration form to set up an appointment for yourself or a family member. Once we receive your contact information will reach out to set up your first appointment. You are also welcome to contact the office directly with any questions that you may have regarding receiving individual or family counseling at our office – (386) 449-8600.

Client Name *

Date Of Birth *

Best Days/Times For Appointments

Location of Counseling *

In Office Counseling
Secure Video Counseling in your home or office

Reason You Decided To Seek Counseling

Phone

Email *

Address *

Address Line 1

City

State

Zip Code

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

Is The Client Under The Age Of 18? *

Yes
No

Please provide more information related to your plan if you like

Email