Directors Recommendation Request at The Center for Counseling Arts : Secure Contact Portal

First Name

Last Name

Email

Phone

How would you prefer we contact you?

Health Insurance or Self Pay

I would like to use my health insurance

I would like fee for service / self pay

Health Insurance Provider

If applicable, who is your provider?

If not listed above, who is your provider?

Date of Birth (mm/dd/yyyy)

What days & times are you available?

Do you prefer a certain gender for your therapist?

Please describe your concerns & how we can help you on your journey: