Tell me about yourself… Seeking Counseling For * Myself My child My partner Myself & My Partner Myself & A Family Member I Understand Sessions Will Be Via HIPAA Secure Video * YES - Telehealth Counseling Is OK With Me! I Live In The State Of Florida * Yes Your Name * First Name Last Name If Applies: Full Name Of Your Child Client Date Of Birth (Must Be Age 10+) * MM DD YYYY Phone * (###) ### #### May I leave a voicemail? * yes no Email * Do You Hope To Use Insurance? * YES NO Name Of Insurance Company Preferred Appointment Day Monday Tuesday Wednesday Thursday Preferred Appointment Time 5pm 6pm 7pm 8pm 9pm 10pm How Did You Hear About Us? Facebook A Flyer A Friend Or Colleague Grow Google Headway Mental Health Match Other Website Message (If you wish, briefly describe what brings you to seek counseling) Thank you for getting in touch with me! I will be in touch with you by phone by the next business day (Mon-Fri). I look forward to connecting with you soon! Warmly, Elizabeth
