Permission to Email a Confirmation Notice?

Email Address:

Address:

Date of Birth:

Referral Source:

Phone Number:

Secondary Ins Info:

NPCS schedules appointments Tuesday through Thursday 10.30 a.m to 6.30 p.m. Please indicate the days and times you're available for regular appointments.

I'm available the following days: 

I'm available the following times:

I can take the first available appointment because I can flex my schedule, knowing a preferred appointment time may not be available in the near future. 

I am seeking (check all that apply):

Briefly explain the reason you are seeking counseling at this time:

Do you see a psychiatrist or doctor for psychiatric medications?

If yes, list the name and address of the doctor:

Are you seeking services for any of the following (check all that apply:)

Do you have any allergies or aversions to dogs that would prevent you from receiving services at NPCS?

Have you been a client at NPCS in the past? 

If so, did you have a different last/name?