Start Your 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 No

Have you been to therapy before?

Yes No Prefer not to say

How did you hear about us? *

Anything else you'd like us to know

I agree to receive appointment reminder texts from Fresh Start Counseling. Msg frequency varies. Msg & data rates may apply. Reply STOP to opt out, HELP for help. See our SMS Terms and Privacy Policy.

Preferred language for follow-up / Idioma preferido

English Español

If you choose Español, we'll follow up in Spanish and send you the Spanish form. Si eliges Español, te daremos seguimiento en español.

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