Ascend Counseling Services, LLC
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Prospective Client Form
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F.A.Q
Contact
Ascend Counseling Services, LLC
Home
About
Therapy Specialities
Bio
Insurance & Rates
Services
Client Center
Client Portal
Prospective Client Form
Office
Notice of Privacy Policy
F.A.Q
Contact
Prospective Client Form
Fill out the form and we will respond within 48 business hours
Full Lega Name
*
E-mail
*
Phone Number
*
Preferred Method of Contact
Phone
Email
Are you reaching out for yourself, your child, or someone else? If someone else, please specify their name and relationship to you
*
Date of Birth of Prospective Client
*
Date of Birth of Prospective Client
Which method of sessions do you prefer?
In-Person
Telehealth
Hybrid/Both
What is your availability for sessions? (Please check all that apply) *
Daytime (9am-2pm)
Afternoon (3pm-6pm)
Evening (6pm-8pm)
Weekends (9am-2pm)
How were you referred to the practice?
*
Tell us how we can help?
*
Contact Us