Contact Info

First Name *

Last Name *

Preferred Pronouns

Phone *

Email *

Postal code *

Child's Name (Optional)

Child's Age (Optional)

Relationship to the Child (Optional)

Therapy Info

Would your like first availability or work with a specific clinician?

What's the Best Way to Contact You? *

How would you like to receive services? *

In-Person Only

Telehealth Only

Open to Both

Provide 3 Times The Client Is Available for Counseling *

Briefly describe the issue you would like to work on. *

Whom Are You Seeking Counseling For *

Insurance Info (Optional)

Address

What is your Insurance Carrier?

BACK of Insurance Card

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FRONT of Insurance Card

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General Info

Stay up to do on the latest info from ICW?? *

Yes

How did you hear about us? *

Email Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Integrated Counseling & Wellness therapists and/or office staff communicating with me via email or text message

I agree to the Privacy Policy provided by Integrated Counseling & Wellness. By providing my phone number and email I agree to receive communication from the business.