New Client Interest Form

If you are seeking counseling please complete the New Client Interest form below, please complete each question as applicable and make sure to list your availability, once you’ve completed the questionnaire submit. When we’ve received the questionnaire someone from our staff will contact you as soon as possible.  If you would prefer to speak with one of our office staff you may contact us at (559) 738-0700.


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