SCHEDULE AN APPOINTMENT

Please fill out this brief form and someone from our office will contact you shortly to confirm a time and date that works best for you.

Name

First Name

Last Name

Phone

(###)

###

####

Email Address

Date

Todays date

YYYY

Time of Day that works best for your appointment

Reason for Seeking Therapy

Who is your insurance carrier? ex. Blue Cross/Blue Shield

Any Questions? (not required)

You will be required to fill out paperwork at the start of your first counseling session. It may seem like a distraction, especially when you’re nervous, but it protects your rights, secures your consent to engage in therapy, and informs you about our policies.

Address:

302 S Kitchell Ave Suite B

Olney IL 62450

Phone:

618-354-0878