Outpatient Therapy Intake - Fresh Start Counseling

Request Outpatient Therapy

Complete this form to get started. Our team will contact you within 24-48 hours.

1 Who is seeking services?

Myself

Individual therapy

Family Member

On behalf of someone

Couples

Couples therapy

2 Contact Information

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Address

3 Payment Information

Do you have insurance? *

Yes, I have insurance

I'd like to use my insurance

No, I'll pay cash

Self-pay / out-of-pocket

Insurance Provider *

Member ID

Group Number

Please upload photos of both sides of your insurance card. This helps us verify your coverage before your first session.

Insurance Card - Front

Upload front of card JPG, PNG, or PDF

Insurance Card - Back

Upload back of card JPG, PNG, or PDF

Flex/HSA Card Photo (optional)

If you have a flexible spending account (FSA) or health savings account (HSA) card, upload it here. This is often used for copays.

Upload flex/HSA card If you have a medical spending card

5 Availability

Select your preferred appointment times:

Weekday Mornings

Weekday Afternoons

Weekday Evenings

Saturdays

Sundays

Flexible / Any Time

6 Additional Information

Last step - you're almost done!

Emergency Contact

Do you have any known allergies?

Yes

Have you been to therapy before?

Yes

Prefer not to say

How did you hear about us?

Anything else you'd like us to know

I consent to receive SMS/text message reminders from Fresh Start Counseling regarding my appointment. Message and data rates may apply. (Recommended)

By submitting this form, you agree to our Privacy Policy and Terms of Service.

Fresh Start Counseling