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HOME
SERVICES
GROUP SCHEDULE
THERAPISTS
FAQ
CONTACT US
NEW CLIENTS
HBH INFO

HOME
SERVICES
GROUP SCHEDULE
THERAPISTS
FAQ
CONTACT US
NEW CLIENTS
HBH INFO

New Client FormLorenzo A2025-09-26T10:21:51-04:00

new client interest form

WE HAVE MOVED!

We are now located with two new offices in Toms River, NJ and Tinton Falls, NJ.
IMPORTANT TO PLEASE CALL US FOR MORE DETAILS AT (732) 477-0862

Your Name *

Phone *

Your Email *

Preferred Method of Contact *Phone CallEmailText MessageCheck Any That Apply

Best Time To Contact You *Week DaysWeek NightsWeekendsCheck Any That Apply

Insurance Plan *

How Did You Find HBH? *Previous ClientFriend / Family Is A ClientTherapist / Treatment Center ReferralInsurance Company ReferralInternet Search / Social MediaOther

Please Note

Due to NJ laws regarding consent to treatment, we will need to speak directly to any potential client over the age of 16 prior to scheduling an appointment.

Who Are You Seeking Treatment For? *MyselfMy Child / ChildrenSomeone Under My Legal GuardianshipMy Spouse / PartnerOther

Age Group of Person Seeking Treatment *Young Teen (Ages 13-15)Teenager (Ages 16-18)Young Adult (Ages 18-25)Adult (26+)

Therapy You Are Seeking? *IndividualGroupCouplesFamily

Have You Been In Therapy Before? *YesNo

Preferred Method for Therapy *Virtual / OnlineIn PersonNo PreferenceCheck Any That Apply

Your Availability for Sessions *Weekday MorningsWeekdays AfternoonWeekdays EveningsWeekend MorningsWeekends AfternoonWeekends EveningsCheck Any That Apply

Reason For Seeking Treatment *Bipolar DisorderDepressive DisorderAnxiety DisorderObsessive Compulsive Disorder (OCD)Trauma DisorderEating Disorder(s)Substance Use DisorderOther Addictive DisorderStressGriefLife TransitionAD/HDBorderline Personality DisorderMood Disorders (Unspecified)SexualityCheck Any That Apply

If You Selected "Other" or Do Not See Your Treatment Needs, Please Provide Below Any Additional Information.0 / 50

Have You Been Diagnosed With ANY of the Above Selected Disorders? *YesNoNot Sure

Additional Information

Consent *

Yes, I agree that I have provided my information to best of my knowledge and agree to being contacted by HBH Counseling.

Please do not fill in this field.

HBH Counseling
Toms River, NJ & Tinton Falls, NJ

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