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* PLEASE READ CAREFULLY AND COMPLETELY *

  • As a counseling clinic, we are mandated reporters of suspected abuse or neglect of children, elders, or vulnerable adults. If you disclose such information on this form, we may be required by law to report it to the appropriate authorities for the protection of those involved. We take confidentiality very seriously, but in cases where we are legally obligated to report, we must prioritize the safety and well-being of vulnerable populations. If you have any questions or concerns about this policy, please don't hesitate to reach out to us prior to completing a form.

  • Individuals shall be considered for entry without regard to race, ethnicity, gender, gender identity, gender expression, sexual orientation, religion, creed, national origin, age (except when program eligibility is restricted to children, adults, or older adults), familial status, marital status, source of income, and disability.

  • We are not currently accepting clients for couples counseling. We apologize for any inconvenience this may cause.

  • *please provide up to date and accurate insurance information to help ensure our billing team can verify coverage and complete the billing profile.*

CLIENT ENROLLMENT FORM

Please fill out the following form to give us information about why you or your family members' need counseling. The more specific information you provide us with the better. We will use this information to determine if we are a good fit and how we can help. 

After completing an enrollment form, we will contact you directly within approximately one week if we are able to work with you. At that time, we will discuss our waiting list and intake process. If we feel like you are not a good fit for our group/specialty we will send you an email to let you know and will include referral options.

We understand that sometimes the need for counseling comes out of a traumatic experience or a crisis type situation. We want to be sensitive and responsive to situations that need immediate help/assistance. If you are needing to talk to someone immediately, please free to call us at (971) 200-1966.

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