Appointment Interest Form

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Thank you for your interest in potentially scheduling with Aspire Counseling Center, LLC. This form is to just collect a little more information. We currently have a waitlist and we will be in touch as soon as we have availability.

Thank you!
Christine Hurst, LCPC & Supervisor,
Angela Knuckles, Intern
& Rachel Radandt, Intern

First Name *

Last Name *

Phone number? *

Accept text messages? *

Yes

Email address: *

Date of birth: *

YYYY

Briefly describe why you are seeking therapy? *

Preference for modality: *

In-person

Online

Either

Please select all appointment days/time that work for you:

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Mornings (9am-12 pm)

Afternoons (12pm -4 pm)

Evenings (4 pm- 7pm)

None work or I am unsure. Please explain in comment section.

If you have insurance, please list it below. Otherwise, type N/A (not applicable). *

I am open to scheduling an appointment with an intern. *

Yes

Maybe

Comments/Questions

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