New Clients - Well Way Counseling

Name *

First

Last

Email* *

Phone Number

INSURANCE PROVIDER *

TYPE OF THERAPY *

ARE YOU COMFORTABLE WITH US LEAVING A MESSAGE IDENTIFYING OURSELVES AS Well Way Counseling & Evaluations AT THE PHONE NUMBER YOU PROVIDED? *

PREFERRED METHOD OF CONTACT *

PREFERRED LOCATION *

IF IN PERSON ISN'T AVAILABLE, ARE YOU COMFORTABLE WITH VIRTUAL *

WOULD YOU BE COMFORTABLE STAYING VIRTUAL? (Never moving to in-person therapy) *

PREFERRED LANGUAGE *

PLEASE TELL US A LITTLE BIT ABOUT WHAT YOU'RE LOOKING TO GET OUT OF THERAPY *

DAILY AVAILABILITY (CHECK ALL THAT APPLY)

HOURS OF AVAILABILITY (CHECK ALL THAT APPLY)

WHO REFERRED YOU TO US? *

IF APPLICABLE, PLEASE PROVIDE THE NAME OF THE PERSON AND/OR COMPANY WHO REFERRED YOU TO WELL WAY COUNSELING & EVALUATIONS? *

Who referred you?

Attorney name?