Appointment Request - Beautiful Journey Counseling®

Client's First Name*

Client's Last Name*

Is the client a minor (under 18 years of age)?*

Parent's First Name*

Parent's Last Name*

Email*

Phone*

Have you already spoken to our New Client Coordinator?*

What is your availability in the next 24 hours for a call back from our New Client Coordinator?*

Please select your insurance*

Please enter your specific insurance*

Please enter your date of birth (or the date of birth of the client if they are a minor).*

Policy Holder name*

Policy Holder Date of Birth*

Potential Client Name*

Potential Client Date of Birth*

ID Number*

Group Number (if not sure, please enter N/A)*

Optional: Upload insurance card front/back to verify your insurance benefits

Front

Max. file size: 256 MB.

Back

Max. file size: 256 MB.

What state do you reside in?*

What city / town do you live in?*

Please enter the state and city / town you reside in:*

What kind of counseling are you seeking?*

Please enter other issue(s):*

Do you know which of our therapists you would like to work with?*

Please select the therapist you would like to work with.*

When are you available for therapy sessions? (please include days and time frames of your availability)*

How did you hear about us?*

Please specify how you heard about us.*

Please enter the name of the professional you were referred by*

Please enter the name of the school you were referred by*

Tell us briefly (in 1 or 2 sentences) why you are seeking counseling services at this time?*

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Beautiful Journey Counseling®