Appointment Request Form Name: * First Name Last Name Parent/Caregiver: (required if under 18) First Name Last Name Email: * Phone: * (###) ### #### Date of Birth: * MM DD YYYY Therapist Preference * Female Male No gender preference Primary concerns or goals for seeking therapy: * How do you plan to pay for your sessions? * Blue Cross Blue Shield Self Pay Terms of Use * By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Waterstone Counseling Center harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means. Yes, I want to submit this form Your request for an appointment has been submitted and someone will get back with you shortly. Thank you!
