Butterfly Counseling Patient Inquiry Form
Please fill this form out and we will be in touch!
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Patient First Name *
Patient Last Name  *
Patient DOB *
MM
/
DD
/
YYYY
If the patient is a minor, please provide parent/ guardians name.
Reason for needing therapy? *
Email Address *
Would you like to sign up for the Butterfly Counseling Subscription Plan? 
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Would you like to be added to Butterfly Counseling's Newsletter? 
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Phone Number *
In-Person or Virtual *
Do you require any accessibility accommodations? *
If yes, please describe what accommodations that you would need
Preferred Time of Day for Appointments *
Insurance - If your insurance is NOT listed then we can offer a self-pay rate to be seen.
**Not all of our clinicians are paneled with all insurances listed**
 *
Therapy Requesting *
Would you prefer a male or female?
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LCAS- Addiction Therapy (Virtual Only)
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Provider Request - if you want to see a specific clinician. 
April Dupree - Waitlist
Would you be interested in a 15-minute free phone consult with a therapist?
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How did you hear about us?
Is it okay to text or email you? *
Please make sure you respond to someone when they reach out for a consult either by email or text.  If you do not respond then we will remove you from our inquiry.   *
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