New client inquiry form

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Thank you for inquiring about counseling services. Please complete the information below. Please be aware that we can only provide services to individuals who reside in Oklahoma full-time.

Due to the high volume, please note that WE WILL RESPOND WITHIN 3-5 BUSINESS DAYS.

If this request is for a minor, please pay careful attention to the "For Minors" section below for specific instructions.

Email *

Record my email address with my response

How did you learn about Legacy Counseling Services in Broken Arrow, Oklahoma? *

Google or general web search?

Legacy Counseling Service Facebook Page

Another therapist

A friend/family member

Broken Arrow Chamber of Commerce or other Networking Group

My pain doctor, primary care doctor, chiropractor, pastor, etc.

Please give us the name and/or the business who referred you. *

First and last name of person(s) completing this form (if there will more than one person in sessions please list information for all parties) *

Are you a resident of Oklahoma? (If you are completing for someone, please answer for the individuals wanting counseling. If more than one person, each person must be a resident of Oklahoma.) *

Yes

Which type of counseling are you inquiring about? *

Individual Counseling

Premarital Counseling

Marriage Counseling

Required

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