Beyond Counseling

Please complete the form and our clinical receptionist

will be in touch within 24 hours of submission.

Full Name

Phone

What type of counseling are you seeking?*

If child, please enter name:

What symptoms are you experiencing and for how long?

From your perspective, please rate the level of impact your symptoms are having on your mental health and daily functioning:*

Are you seeking in office visitation or telehealth?*

Will you be using insurance or private pay?*

Name of Insurance (if applicable)

Patient's Date of Birth (MM:DD:YYYY)

Do you have a preferred therapist? If so, please write the name of the therapist.

What is your availability within the next week for a 10-15 consultation?

Additional Notes