JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Resilient Roots, Counseling and Consulting - New Client Inquiry Form
Please complete this form and we will respond to you as soon as possible!
Nurturing Growth ~ Strengthening Resilience
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Name you go by / Preferred name
*
Your answer
*
MM
/
DD
/
YYYY
Email
*
Your answer
Is it ok to email you?
*
Yes
No
Phone
*
Your answer
Is it ok to call you and leave a voicemail?
*
Yes
No
Gender
*
Man (cisgender)
Woman (cisgender)
Agender
Gender fluid
Gender nonconforming
Nonbinary
Queer
Trans man
Trans woman
Prefer not to say
Other:
State you live in
*
North Carolina
South Carolina
Colorado
Other:
Do you plan to use your health insurance plan?
*
Yes
No
Other:
Primary insured name and date of birth
Your answer
If using your health insurance plan, please
include
Company, Plan Name, etc.
Your answer
If using your health insurance plan, please
include
Member ID
Your answer
What type of therapy are you interested in?
*
In Person
Telehealth
Either
In a couple sentences, please describe the reason you are seeking therapy.
*
Your answer
Do you have specific days and times in mind for therapy?
*
Your answer
How did you hear about us?
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of resilient-roots-counseling.org.
Does this form look suspicious?
Report
Forms
