District Counseling New Client Intake Form

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District Counseling New Client Intake Form

Thank you for your interest in therapy services from District Counseling LLC. Please complete this questionnaire in its entirety and once completed you will be contacted by a member of the D.C. team with details on next steps.

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* Indicates required question

Email *

Your email

Please enter your full name. *

Your answer

Please enter Birthday *

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DD

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YYYY

Please enter your primary phone number. *

Your answer

Please enter your insurance provider or indicate if you plan on being a cash pay client. *

Ex. United HealthCare or Cash/ Out of pocket client

Your answer

How did you find out about District Counseling LLC? *

Your answer

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