Name of person needing services:

First Name *

Last Name *

Date of birth *

Names of Parents / Caregivers if patient is a minor

Email *

Phone *

Address *

Street Address 2

City *

State *

Postal code *

Tell us about what you are needing help with *

If the patient is a minor, we will need consent from both parents/caregivers. We will also need a copy of the custody agreement/divorce decree before we can start services.

We try to accommodate our client's scheduling needs; however, after school and weekends are the most requested times. If you have more flexibility in your schedule, we will be able to get you in sooner.

Appointment Availability *

All of our therapists are In Network with Cigna and Aetna. We are out-of-network with other insurances.

How did you hear about us? *

I understand that communications via SMS and email over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email can be intercepted and read by other parties besides the person to whom it is addressed. I also understand that Reach Counseling staff will coordinate our initial phone consult, in which I permit to leave me a message at the phone number and email address provided.