Full Name *

Phone *

Email *

How did you hear about us? *

Yes, text me from Pivot Counseling. It's the fastest way for our team to reach you about scheduling and appointment reminders, plus occasional updates. Message frequency varies. Message & data rates may apply. Reply STOP to unsubscribe at any time.

Please tell us about why you’re reaching out for services today. What areas would you like support in? What would you like to be different in your life? It’s important that we are able to provide you with the best support possible. Thank you.

The following questions pertain to the responsible party filling out the paperwork on behalf of themselves, their child, or their family.

What level of education have you achieved?

Education Level

What is your approximate annual household income?

What is your current employment status? *

Pivot is an out-of-network provider. Do you plan to use your out-of-network benefits?

We don't bill insurance and aren't in any insurance network. You pay at each session. If you have a PPO plan, we give you a superbill (a receipt you send to your insurance) so they may pay some of it back. HSA/FSA cards are welcome.

You pay $250 to $400 per session at the time of your visit, before any reimbursement. Does that work for you? *