Name
*
First Name
Last Name
Email Address
*
Phone Number
*
(###)
###
####
May we leave you a message?
*
What is your preferred method of contact for scheduling?
*
Phone
E-Mail
Text Message
What format of services do you prefer?
*
In Person - Austin, TX
In Person - Houston, TX
In Person - McAllen, TX/Rio Grande Valley
Virtual
Ecotherapy
I'm open to all of the above
Who are you contacting us about?
*
Myself
A Minor Child
An Adult Dependent
Other
What is your age?
*
Primary Client Name
*
(If you are filling this out for someone else, please include their name here.)
First Name
Last Name
What is your relationship to the primary client?
*
Myself
My partner
My child
Other
Pronouns
*
What kind of therapy are you seeking?
*
Do you know which counselor you'd like to see?
*
Colors of Austin Counseling accepts BCBS, Aetna, and Self Pay clients. Please visit our bio page for more information about each therapist.
These qualities are most important to me in a therapist:
*
What topics do you want to explore in counseling?
*
Check all that apply.
Do you have specific scheduling needs?
*
Please select as many as possible to help with scheduling.
How often would you like to see a therapist?
*
Weekly
Bi-weekly
Monthly
Unsure
What is most important to you in finding a therapist?
*
Personal Fit/Connection
Location
Cost
Other
What are your payment preferences?
*
Choose all that apply.
How did you hear about our practice?
*
Is there anything else you'd like us to know at this time?
*
If you are seeking another type of service, let us know which one.
Questions
Comments
I'm interested in one of your Groups/Workshops!
I'm interested in getting supervision with Vanessa Newton!
I'm interested in getting supervision with Becky Morales!
I'm interested in getting supervision with Alexandra DeHoff!
