First Name
*
Last Name
*
Email
*
Phone
*
Date of birth
Address
*
City
State
Postal code
*
Presenting Problem
Scheduling Preferences
Morning
Afternoon
Evening
Weekdays
Weekends
Method of Payment
Out of Pocket
Insurance Company
Insurance Name
Only if the client is a minor: First and last name of guardian and relationship to the child
Email Risk Acknowledgement and Use Consent
*
I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Peace-Filled Mental Health Counseling Services therapists and/or office staff communicating with me via email or text message
Submit