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New Client Information

Please fill out the following information prior to first visit. Please ensure all information is filled out to the best of your ability. Additionally, copies of insurance card (front/back) must be submitted to counselor once assigned.

Thank you!


Preferred Name

Legal Gender

Gender Identity

Email Address

Date of Birth


City, State, Zip

Phone Number

Primary Insurance /Responsible Party


Marital Status

Name of Spouse (If Applicable)

Name of Insurance Guarantor (If Not Client)

Date of Birth of Guarantor (If Not Client)

Requested Counselor

Presenting Problem


Preference: telehealth or in person?

Preference: Male or Female Counselor?

Preference: Caucasian counselor or counselor of color?

How did you hear about our services?

*By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Submit," you agree to hold Awareness To Change Counseling and Consulting Services harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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