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New Client Inquiry Form
Thank you for your interest in Renewed Counseling & Play Therapy! Please fill out the form below with as much detail as possible, and we will reach out to you shortly with scheduling and intake information.
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First and last name:
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Your answer
Birthday:
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MM
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DD
/
YYYY
Email address:
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Your answer
Phone number:
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Your answer
What issues are you hoping to address in counseling?
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Your answer
Would you prefer to meet in person or virtually?
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In person
Virtually (you must physically be in the state of NC for all virtual sessions)
A mix of both, depending on schedule
Doesn't matter to me
When are you available to have counseling sessions?
The more options you choose, the more likely we will have availability to accommodate your schedule.
Morning
Afternoon
Evening
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning
Afternoon
Evening
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Is there anything else you would like us to know?
Your answer
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