CHANGE THROUGH CONNECTION

Please complete the form below if you are interested in becoming a client. Submitting this form does not guarantee an appointment, scheduling is based on current availability. I cannot guarantee the confidentiality of this form please only share what you are comfortable with.

Name

First Name

Last Name

Email

Pronouns and Gender

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Referred By

Primary Insurance

What are you hoping to address in counseling?

What goals do you have for therapy?

What is your previous experience with therapy and/or mental health medications?

What questions do you have for me?

CHANGE THROUGH CONNECTION

ROSE AND FERN COUNSELING