McGuire Christian Counseling New Client Form
We are so glad you are here!  It is our goal to honor Christ by coming alongside our clients with caring hearts. We have professionally trained counselors who are ready to provide you with the help you need.

 Please note we currently only have therapists to see clients ages 15 and older.
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Today's Date *
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Client's FIRST Name *
Client's LAST Name *
Client's Birthdate (Please double-check that you are entering the client's date of birth.) *
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Email (for correspondence regarding account set up, appointment reminders, etc.) *
Phone Number (including area code) ###-###-#### format *
Name of person completing the form *
Relationship to the client *
Have you been a client of McGuire Christian Counseling previously? *
Type of Counseling Desired  (Please complete a new form for each type you are requesting) *
I prefer to attend sessions: *
Pay Source: Which of the following will you be using for this client?  *
If using Insurance, please indicate which Insurance (If your insurance is not listed, we do not currently have an in-network provider).  All insurance plans and benefits are different and are subject to various limitations.  It is the client’s responsibility to investigate insurance benefits and coverage and be aware of their financial liability for services received. *
If an Employee Assistance Program is being used, please indicate the name of the EAP. 
If using EAP, please provide the authorization number and number of sessions approved (If not using, please state N/A) *
If your church or business will be paying, please indicate the name of the church or business and contact person including an email address. (If not using, please state N/A) *
Request for specific therapy or therapist (optional, specific requests may extend waitlist time). 

Providers listed are the only providers accepting clients at this time. 
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Request for specific day(s)/time(s) can be listed here. (optional, specific requests may extend waitlist time)
How did you hear about McGuire Christian Counseling?
Message: (optional)
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