Client's Legal Name (required for Insurance purposes) *

First Name

Last Name

Client's Preferred Name (if different from above)

First Name

Last Name

Client's Date of Birth *

MM

DD

YYYY

Phone Number *

(###)

###

####

Communications Method *

Please indicate which method(s) of communication you consent to receive.

Phone Call

Email

Text Message

Voice Message

-All of the Above-

*

Which method of communication do you prefer to receive?

No Preference

Phone Call

Email

Text Message

I certify, I only have one insurance carrier. *

Yes

No, I have a Secondary Insurance

Which counselor do you prefer to work with? *

Unsure; I would like the referrals coordinator to match me with a counselor

Michael Tui, LCMHC, NCC

Leighton Hannah, LCSW

Joe Hannah, LCSWA,LCAS

Dr. Anurag Mani, LCMHCA, LMFTA

Don Killian, LCMHC

Paul “Rob” Phelan, Pastoral Counseling & Life Coaching

Monica Michelle, CPLC

Taft Draper, RD

Other