Intake Scheduling

Thank you for choosing The Gentle Shepherd Counseling Center. To schedule your first appointment, please complete the following and one of our secretaries will respond to you as soon as possible. Please see our business hours for more information.

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Client Name *

First

Last

Age *

If under 13 years of age, please specify *

Contact Name *

First

Last

Phone Number *

Messages OK *

Yes No

Insurance/EAP Provider *

Place of Work/School *

Referral *

Reason for Coming/Counselor Preference *

Other Information/Availability *

Submit

Notice: Weebly is a secure, encrypted website, but our email is not subject to the same level of security. However, any and all information provided through this intake is confidential and your responses will only be used by our office staff and counselors. We follow HIPPA regulations of client privacy and information security.