New Client Interest Form

If you are seeking counseling please complete the New Client Interest form below and submit, once received, one of our staff will contact you within 24 hours.  If you would like to speak with someone you may call our office at (559) 738-0700.


Today's Date *
Today's Date
New Client Information
Name *
Name
Address *
Address
Date of Birth *
Date of Birth
Please list days and times you are available*
Name Parent/Legal Guardian
Name Parent/Legal Guardian
(if minor)
Phone *
Phone
Message Preference *
Therapist Preference *
Please select up to 2 therapists
Insurance Information
Name of Insured *
Name of Insured
Insured DOB *
Insured DOB
Provider Services Phone
Provider Services Phone
Anything Else We Need to Know?