If you are currently experiencing a mental health crisis, DO NOT complete this form.
Call your local crisis center or go to your nearest emergency room. Submitting this form does not guarantee that you will be scheduled with one of our providers. Clients are contacted in the order that requests are received, based on their preferences below. We cannot guarantee a specific response time.
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First and Last Name *
Contact Information *
Enter your email address and/or phone number below. Email will be sent only one time so check junk files - emails will come from Admin@bullcitycounseling.com or directly from a clinician's email address.
I would like to schedule: *
Preferred Clinician *
Please select all options that you are willing to consider. Multiple selections are allowed and encouraged. The more flexible you are, the quicker we will be able to find  a match for you.
Required
Health Insurance *
If you are willing to be seen out-of-network, we will file insurance claims electronically on your behalf. Currently, telehealth sessions are being covered at the same rates/copays as face to face sessions!
Required
Availability
Our clinicians do not work evenings or weekends. Our business hours are 8a-5p. Please select all appointment times that might work for you. Please note the time ranges are the START times for appointments.
Monday *
Required
Tuesday *
Required
Wednesday *
Required
Thursday *
Required
Friday *
Required
By submitting this form,  I authorize Bull City Counseling, PLLC to reach out via email and/or phone when scheduling options become available. I understand that I can edit my responses and remove myself from this waitlist at anytime.  I understand this form does not guarantee scheduling and I will seek immediate mental health care if an emergency arises.
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