Appointment Request | Ocean Vista Counseling

An appointment request with Ocean Vista Counseling is very easy, please complete the following form to set up an appointment for yourself or a family member. Please provide information related to what you would like to work on in counseling and also information on your insurance coverage. Our office staff will be happy to check your benefits and advise you of your financial responsibility.

We will then email you a link to Simple Practice our practice management software, this is where you will complete the intake form and counseling consent forms. We do ask that you complete the forms in a timely manner. This will provide your counselor an opportunity to prepare for your session ahead of time.

Please provide your contact information and we will reach out to set up your first appointment. You are welcome to contact the office directly with any questions that you may have regarding receiving services at Ocean Vista Counseling. Our office provides both individual and 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? *

Please provide more information related to your plan if you like

Comment