Appointment Request Form
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Have you been seen at Bull City Counseling in the past? *
Required
First and Last Name *
First and Last Name
Contact Information *
Please enter your email address and/or phone number below. Be careful and check for typos!
I would like to schedule an appointment for: *
I would like to be seen: *
Health Insurance *
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
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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