Counseling Registration Form

PLEASE NOTE THAT IF YOU ARE COMPLETING THIS FORM ON A COMPUTER WITH A STRONG FIREWALL, YOUR RESPONSES MAY NOT GO THROUGH. 

PLEASE USE A PERSONAL COMPUTER OR MOBILE DEVICE IF POSSIBLE. 


Once this information is received, you will receive a 

follow up email within 24 business hours. 

Please check your spam folder or call if you do not receive a response. 

Type of Counseling
Patient Gender*
Age Range*
Form of payment (will obtain more info later)*
The necessary forms will be provided for you to file out of network for partial reimbursement. List your preference here.
Session availability (best days for you)
Preferred time of day
How did you find out about Emily Newberry?*
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