Appointment Request Form – Baybrooke Counseling

Your Name

First

Last

The person seeking treatment prefers to be called

(First name, nickname, Ms. X, Mx. X, etc.)

Age of person seeking treatment

I work with patients 16+

Email

Phone number

Please enter a valid phone number.

Issues of concern (check all that apply)

Location of service

Insurance and payment

I only accept the plans listed here. Patients are expected to know their own insurance benefits.

Referral source

Is there anything else you'd like me to know?

By clicking Submit below, you are consenting to receive text messages. We DO NOT send unsolicited texts, only respond to administrative questions or concerns from patients who choose to use texting as a form of communication.