Appointment Request

To schedule please complete the registration form and we will contact you to set up your first appointment. You may also reach us at (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

How Will You Pay *

$135.00 (60 Minutes)
$200.00 (90 Minutes)
Private Insurance
EAP

Please provide more information related to your plan if you like

Email