Free 15-Minute Therapy Consultation Form

15-Mins. Free Therapy Consultation Form

During Clarity Counseling's complimentary 15-minute Therapy Consultation, we'll explore your challenges, goals, and answer any questions you may have. Please fill out the scheduling form and click "Submit" to finalize your request. We'll be in touch shortly to arrange a phone appointment.

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Appointment Type:

Phone Call

Today's Date:

Your Full Name:

First

Last

Are you interested in a particular therapy treatment we offer?

Primary Email:

Who is this consultation for?

If your preferred payment method doesn't work, is there an alternative available?

*Coverage restrictions in commercial healthcare insurance may limit the mental health services available to you.

Phone No. #:

How will you pay for therapy services?

How did you come across our therapy services?

Briefly describe your challenges and any other important information.

Acknowledgment & Submission Consent:

By selecting 'I AGREE' you acknowledge and consent to Clarity Counseling's Privacy Policy and Terms of Use upon submitting our 15-minute Therapy Consultation Contact Form.