New Client Form - HBH Counseling

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 *

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.

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

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

new client interest form

Preferred Method of Contact *

Best Time To Contact You *

How Did You Find HBH? *

Who Are You Seeking Treatment For? *