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Start Your Journey to Mental Well-Being. Complete our Service Inquriy Form!

Fill out our Service Inquiry Form to help us match you with a therapist based on your needs. Your journey to mental well-being starts here!

Completing the Service Screening Form does not guarantee services.

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Complete our Service Inquiry Form

First Name

Phone

Check your issues/concerns * Required

Child/Teen Concerns

Anxiety/Nervousness

Alcohol/Drug Misuse/Abuse

Court Ordered Services

Depression/Sadness

Parenting Struggles

Relationship Issues

Recent Psychiatric Hospitalization

Recent Suicide Attempt

School/Business Inquiry

Last Name

State of Residence

Preferred Time of Appointment * Required

Weekdays Morning

Weekdday Afternoon

Weekday Evenings

Saturday Morning

Saturday Afternoon

Email

Health Insurance/Payment Type

Prefernece for Location

OPTIONAL info -Copy of Insurance Card: Let us verify coverage for services

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OPTIONAL Info -Insurance Member/Client DOB

Completing the Service Screening Form does not guarantee services.

Orchard Blue Counseling Services LCSW, PLLC

(516) 200-1174/(727) 222-3972

info@orchardbluecounseling.com

© Orchard Blue Counseling Services LCSW, PLLC-All Rights Reserved 2021

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