First Name *

Last Name *

Phone *

Email *

Address *

Postal code *

Whom are you seeking counseling for *

Child’s name and age (if seeking services for your child)

Which location(s) do you prefer (indicate all that could work for you) *

Fort Thomas, KY

Crestview Hills, KY

Florence, KY

Telehealth Only

How would you like to receive services? *

In-Person Only

Telehealth Only

Open to Both

How would you prefer we contact you? *

Phone

Email

Text

Briefly describe the reason for seeking services *

Type of services you are seeking *

Insurance Verification

(only if you plan to utilize your insurance)

Date of Birth of Client

Name of Insurance

Insurance ID

Front of Insurance Card (Picture)

Back of Insurance Card (Picture)

Is there anything else you want us to know?

How did you hear about us? *

Email Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to ViewPoint Psych therapists and/or office staff communicating with me via email or text message

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