Hometown Counseling Interest Form
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Thank you for your interest in working with Hometown Counseling! We do not take this decision lightly. We know reaching out for counseling can be intimidating and we do everything possible to make the process as simple and painless as possible! This form does not guarantee services with Hometown Counseling. It serves to express your interest and provide information so Hometown staff can contact you if we have a clinician available that meets your needs.
Client(s) Name *
First and last name
Pronouns you'd like staff to use at this point
Client DOB *
MM
/
DD
/
YYYY
Guardian Name(s) if applicable
Email(s) *
Are you comfortable with us adding your email to our private list where we send out monthly-quarterly newsletters and event updates?
Clear selection
Phone number(s) *
Who referred you to our practice? How did you learn about us?
What type of services are you potentially interested in? *
Required
Do you have a preferred clinician? *
Required
What is your expected payer source for sessions? 

*Self pay rates are always disclosed ahead of services. We are very big on financial transparency. Rates are based on length and service. Sliding scales slots are available on limited basis.
Do you currently have an open court case? *
Please tell us about your scheduling availability. Are you pretty flexible or do you need specific days and times? *
Required
Scheduling: Are you initially looking for weekly counseling? Every two weeks? Something else?
Clear selection
What is your preference for service type/location? Check all that apply *
Required
What brings you in for counseling? Please share as much as you feel comfortable. This information will be used to help match you with the best possible clinician for your needs. *
Is there anything you'd like to tell let us know? Any questions or concerns?
Referrals
If you read through this and decided that our staff may not be a good match due to budget or scheduling needs, feel free to reach out to us directly. If we are unable to accommodate your needs, we're happy to provide you with referrals for other clinicians that might be a better fit. At the end of the day, your health and happiness is most important! 
Thank you for completing this form. We will contact you as soon as we find a clinician that matches your potential needs and availability. If you have questions in the meantime, feel free to email us at happytohelp@hometowncounseling.com
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