top of page

Home
Services
Our Team
Resources
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:

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).

Please note that online submissions are responded to via the email provided in this form. *

I will check my email

By submitting this form, you agree to receive SMS communications from Gateway Counseling. Carrier and data rates may apply. Message frequency may vary. You can reply "STOP" at any time to end messaging, or reply "HELP" for more information.

Thank you. Gateway will reach out to you shortly.

Click here to return to Home.

Minimalist Staircase

Get in touch

Privacy Practices

417.869.8400

1864 S. Kentwood Ave

Springfield, MO 65804

bottom of page