New Horizons Counseling & Wellness

New Horizons Counseling & Wellness Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Date of birth

State

Select the state you live in

Parents Name (if client is a minor)

Clients Name

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Email Address

Phone Number

Client Date of Birth

What town/city do you reside in?

Administrative

Inquiry reason

Referral source

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Facebook Instagram Our Website LinkedIn Referral Psychology Today Google Search School Referral

Driver's license upload

Do not upload sensitive financial information such as credit card information.

If you were referred to us, who referred you?

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Preferred clinician

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Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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What is the name of your insurance company?

Insurance ID Number

If no insurance, type N/A

Billing & Payment

Policy Holder Name

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Policy Holder Date of Birth

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Reason for care

Tell us briefly (in 1 or 2 sentences) why you are seeking counseling services at this time?*

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.