Transcend Counseling & Wellness ~ New Client Inquiry Form
Please complete this form to let us know how we may assist you. If you are completing the form for someone other than yourself, enter the client's information.  All questions with * must be completed. If you are not sure of the answer or if the question does not apply to you, please write “Unsure,” “N/A” or “None.” We look forward to meeting you. 


Sign in to Google to save your progress. Learn more
2.2 First name *
2.4 Last name *
3.5 Email address *
2.7 Date of Birth *
MM
/
DD
/
YYYY
3.1 Primary phone number *
3.2 Primary phone name (if this number is not for the patient, to whom does it belong?) *
56.1 Please list primary reason for seeking therapy *
What type of service is preferred? *
For counseling, our current availability is as follows:
In-Person: Mon, Wed & Thurs, 8am-11am and 1pm-5pm
Telehealth: Mon - Thurs, 8am-11am and 1pm-5pm
Please let us know your preference for day and/or time. We will schedule you for the first appointment available that meets your preference. You will receive a confirmation email. If you have a conflict with the date/time, please let us know and we will contact you to change it. 
 *
4.1 Payment preference *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of J. & D. Phelan & Co., L.L.C. Report Abuse
Google Forms