New Clients

At Behind The Veil Consultations, PLLC, we are dedicated to providing a compassionate and supportive environment for your healing journey. Our team of experienced therapists is here to help you navigate life’s challenges with faith-based counseling tailored to your unique needs. We look forward to partnering with you on your path to wellness and growth.

New Client Form

Today's Date

First Name

Last Name

Email Address

Phone

Street Address

City, State, Zip

Insurance Company

Insurance Customer Service Number

Insurance Subscriber's Name

Subscriber Date of Birth

Subscriber Policy #

Group #

Subscriber SSN

Subscriber Employer

Client's Relationship to Subscriber

Client's Date of Birth

Desired Appointment Day (If Any) Desired Appointment Day (If Any) Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Desired Appointment Time

Desired Counselor Name (Optional)

Desired Location(s)

Desired Appointment Time

Brief Explanation for Seeking Counseling

Message

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