First Consultation Request.

Schedule Your First Consultation.

Hello and welcome Greensboro Counseling and Consultation. Please take a few minutes to give us some more information that will help us to ensure you are matched up with the counselor best suited for your work in therapy. Please know this form is confidential.

Once this form is completed and sent back to us we will reach back out to you usually in the next 48 hrs.

Name*

E-mail*

Phone

Best way to communicate with you:

Phone Call Text Email

Brief description of what you are looking to work on in Therapy:

Provider Preference (if any):

Appointment Time Preference (Check all that apply):

Morning Afternoon Evening No Preference

In Person/Virtual Preference:

In Person Virtual No Preference

Finances:

Insurance Self-Pay:

Please know at this time our out of pocket rates are from $125-140 per session. We do work with Blue Cross Blue Shield Insurance and your copay for services is different for each individual plan. This information will be provided before the first session once we are able to verify your insurance benefits.

If using Insurance:

Client DOB:

Name of policy holder:

Policy holder DOB: (Client’s name if different from above):

Front of Insurance Card

Back of Insurance Card