New Client Request

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

First Name

Last Name

Date of Birth

Email

Select your preferred provider, if applicable.

Phone

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

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Country

Insurance

For our office staff to successfully verify eligibility and benefits, kindly provide insurance information. You may also upload a photocopy of your insurance card, for easier submission.

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

Policy #

Group #

Upload File

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Thank you for your submission.

New Client Request Form

SERVICES
Individual Therapy
Couple and Family Therapy
Group Therapy

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