New Client Request

New Client Request Form

Thank you for your interest in The Therapy Corner Counseling & Consulting, PLLC

Client Full Name

Parent/ Guardian Name or Partner / Spouse Name

Date of Birth

Select your preferred method for appointments.

In-Person

Telehealth

Type of Counseling you are looking for (please check all that apply):

Indiviual Therapy

Indiviual Therapy (Minor)

Couple or Family Therapy

Group Therapy

Phone

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Name of Insurance Company (If you'll be using an EAP, a voucher, or self-pay, please elaborate below).

Member ID

Group/ Policy ID

Photocopy of your Insurance ID card

Upload File

Thank you for your submission.