First Name *

Last Name *

Phone *

City *

Email *

Are you currently taking Psych Medications? *

Are you currently taking Psych Medications?

What questions do you have *

What symptoms are you hoping to resolve? *

Anything else you want us to know? *

Which do you prefer? *

In-Person Sessions

Telehealth Sessions

How do you plan to pay? *

Insurance

Self-pay out of Pocket

If planning to use Insurance, who is your provider? *

Are you completing this form for a minor or someone other than yourself? *

Yes

While we will determine the treatment that is best for your symptoms, in which services are you most interested? *

What times are you available on these days? *

Mornings

Daytime

Evenings

By checking this box, I consent to receive non-marketing text messages from Pneuma Counseling about appointment scheduling and consultation follow-up. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers and updates from Pneuma Counseling at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.