Book An Appointment

To request an appointment, please fill out the form below:

Request Appointment COPY of Original

Client's First Name

Client's Last Name

Phone

Potential Client Date of Birth

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

Parent's First Name

Parent's Last Name

Have you already spoken to our New Client Coordinator?

Insurance Info

Policy Holder First Name

Policy Holder Last Name

Policy Holder Date of Birth

Please select your insurance

Please enter your specific insurance

Insurance ID Number

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

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

Front

Maximum file size: 5MB

Back

Maximum file size: 5MB

What town/city do you live in?

What state do you reside in? What state do you reside in?

What kind of counseling are you seeking?

Please enter other issue(s)

Couples Info

Partner's First Name

Partner's Last Name

Partner's Email

Partner's Phone

Partner's Date of Birth

Second Partner's First Name

Second Partner's Last Name

Second Partner's Email

Second Partner's Phone

Second Partner's Date of Birth

Please indicate any applicable issues:

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

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

How did you hear about us? How did you hear about us?

Please enter the name of the school you were referred by

Professional Referral Name:

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

Captcha

If you are human, leave this field blank.

Individual and Group Therapy for Adults, Adolescents and Children

Contact Info:
551-319-2029
fax: 201-399-3563
Beautiful Journey Counseling
Mahwah Location:
860 Wyckoff Ave.
Suite 303
Mahwah, NJ 07430
(View Google Map)
Midland Park Location:
666 Godwin Ave.
Suites 300 and 330
Midland Park, NJ 07432
(View Google Map)
Beautiful Journey Reproductive Counseling Center
Mahwah Location:
860 Wyckoff Ave.
Suite 206
Mahwah, NJ 07430
(View Google Map)

BOOK AN APPOINTMENT