New Client Appointment Request Form
DISCLAIMER: To begin services with Pivotal Breakthrough Counseling Services, PLLC please fill out the form below. Filling out this form will generate an appointment request. We will connect you with the most appropriate clinician in the practice based on your needs and availability. 

Please allow our administrative team 24 hours to contact you back to verify your information and schedule your initial intake appointment. Please supply the most accurate availability times so that our administrative team can schedule you at the appropriate time.

Once an appointment is scheduled, the client will receive an email from SimplePractice with instructions on how to complete paperwork before their scheduled appointment. We look forward to serving you!

Please Note: If documentation, insurance, and payment are not completed 24 hours before the planned session, the session will be canceled.
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Full Name and Last Name *
Email address *
Phone Number *
Date of Birth *
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Referral Source
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Insurance Type *
Appointment Request For: *
Required
Seeking Treatment For *
Required
Desired Appointment Time *
Desired Clinician *
Method of Appointment (please note: most providers are telehealth only) *
Required
Do you have any current or previous history of suicidal thoughts or suicide attempts, or other self-harming behaviors (ex. cutting, eating disorder, substance abuse)? *
Is there anything else we should know? *
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