New Light Counseling LLC | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

Describe your current living situation.

Do you live in an apartment, house, duplex, other

Please list your preferred pronouns.

Billing & Payment

Insurance details

Please list insurance provider name, policy number and group number.

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Client Preferences

Preferred appointment times

Please list days of the week and times (typically sessions are 1-hour blocks) you are available for session. The more days and time listed may lead to getting scheduled sooner. Please only list days and times you can commit to attending regularly.

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Preferred modality

Are there any additional details you would like to share with the counselor?

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Please list preference for gender of your counselor. Please notes if a preference is indicated, other options will not be given at time of communicating potential scheduling times.

Male Counselor Female Counselor No Preference - First Available

Thank you for taking the time to complete this scheduling form. Our scheduling team will reach out to you within the next few days with next steps. We look forward to working with you!

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.