Schedule an Appointment Form Website

Name*

Date of Birth

ADDRESS

CITY

state

zip

Desired Location*
Please provide your contact number, the type of health insurance, and a few words explaining your situation. Someone will contact you within 24 hours to schedule an appointment.

How do you prefer to be contacted?

Email Address*

Cell Phone*

Home Phone

We offer day, evening and weekend appointments; please provide us with your preferred day(s) and time(s) in order of preference

PREFERRED DATE(S)

Date #1

Date #2

Date #3

PREFERRED TIME(S)

Time #1

AM/PM Option

Time #2

AM/PM Option

Time #3

AM/PM Option

Please let us know if you have a preference of therapist.
Preferred Therapist
Preferred Therapist
Preferred Therapist
Preferred Therapist
Preferred Therapist
Preferred Therapist
Please provide us with a brief description of your presenting challenge(s) and/or important information that will help us serve you better!
Description
Do you look for in-person or telehealth counseling?
For verification if CCC Counseling Services accept your insurance, please fill out below.
Type of Counseling
Please provide us with your insurance name and policy number, so that we can verify your benefits for you.

Name of Insurance Company

Policy ID Number

Insurance Group Number

Name as it appears on your insurance card

Mental Health Customer Service number on back of your card

For verification if CCC Counseling Services accept your insurance, please fill out below.