top of page
Home
Services
Our Team
Contact
More
Use tab to navigate through the menu items.
New Client Form
Client's First Name
Email
Address
Today's Date
Client's Last Name
Phone
Client's Date of Birth:
Name of Person Completing form
Relationship to Client
Self
Parent
Guardian
Spouse
Other
Type of Counseling Desired:
Individual
Family
Marital
Couples
Premarital
Pay Source:
Self Pay
Insurance (all insurance plans and benefits are different and are subject to various limitations)
If using insurance, please list type of insurance and Member ID:
If you are not the the policy holder for your insurance, please list the name of the policy holder:
Policy holder's Date of Birth:
Request for specific provider and/or specific day(s)/time(s) preferred for appointment (Optional).
Send
Thank you. Gateway will reach out to you shortly.
bottom of page
