If you are interested in scheduling an initial clinical evaluation to begin therapy services,

please complete the new client inquiry form below and I will respond via email as soon as possible.

New Client Inquiry

Name

First Name

Last Name

Phone

(###)

###

####

Is it okay to call or email both of these?

Birthday

Please enter birthdate of potential client

Insurance

What insurance will you be using or will you be a self-pay client?

What would you like help with right now?

What are your or the potential client's general symptoms or issues you or the potential client are experiencing? What do you hope changes for you or the potential client?

Are you currently being seen by other providers?

Do you or the potential client currently receive medication from a primary care provider, psychiatrist or nurse practitioner, or therapy through another provider?

Is there any other information that would be helpful?

Are the services for a child or other person? Do you have specific questions or information that you think it is important to know?

Are you flexible with days/times for appointments or do you need specific days/times?

If there are specific days or times you are needing to schedule, please be as specific as possible (for example: Wednesdays and Thursdays after 3:00pm)

Are you seeking therapy services only?

Are you also in need of medication management with Rosanna Lea NP?

Is there a specific provider you would prefer?

Please identify if you have a preference for a provider.

New Client Inquiry

Thank you! Please be sure to check your email for a response from megan@counselingcornerms.com in the next 2-3 business days.

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