Name
*
First Name
Last Name
If not self, who are these services for?
Email
*
Phone
(###)
###
####
Area of Interest
*
Please check all applicable boxes below
Do you wish to use insurance?
*
Yes
No
Services
*
Individual Counseling
Marriage/Couples/Premarital Counseling
Parent-Coaching/Co-Parenting
Family Counseling
Do you have a preference on which provider you would request to see at Mercy's Place?
*
Select all you are open to see. Mercy's Place does not keep a waiting list. If appointments are out further than 6 weeks, we ask that you check back on availability.
What is your requested time frame for an initial appointment?
*
I wish to be seen within 1-2 weeks
I wish to be seen within 2-4 weeks
I wish to be seen within 4-6 weeks
I wish to be seen as soon as my requested provider(s) is available
Do you have specific requests/needs regarding appointment times?
Referred by
*
Pediatrician/Primary Care Physician
Website/Google Search/Psychology Today
Another Provider
Personal Reference/Friend/Family Member
Pastor/Clergy
Other
Are you requesting that a Christian faith-based integration into evidenced-based clinical counseling be a part of the services?
*
Yes
No
Unsure
Tell us more about your request
Parent Name
First Name
Last Name
Parent Name
First Name
Last Name
Child's Name
First Name
Last Name
Child's Date of Birth
MM
DD
YYYY
Parent's Marital Status
Is there joint legal and physical custody?
Is there any legal or mediation involvement?
Will both parents be involved in services?
Will both parents be aware/giving permission for pursuit of therapy services?
Is your child in school?
Who will be joining you?
Spouse
Fiancé
Significant Other
Child/Other
Name
First Name
Last Name
Age (if under 18)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Email
Phone
(###)
###
####
