Step 1 of 4 — Contact Info

First Name *

Last Name *

Phone *

City *

Email *

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.

Step 2 of 4

Are you currently taking Psych Medications? *

What symptoms are you hoping to resolve? *

What questions do you have or anything else? *

Step 3 of 4

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

Step 1 of 4 — Contact Info

Step 2 of 4

Step 3 of 4

Step 4 of 4 — Scheduling