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New Client Intake

Thank you for considering Neighbors Counseling Services. To help us better understand your circumstances and match you with the most suitable option, please take a few moments to complete our intake form.

Upon submission, you'll be scheduled for a free 15-minute phone consultation with one of our therapy care coordinators. This consultation will help us discuss your needs and answer any questions you may have about therapists or provider availability, insurance information, or private pay rates.

We look forward to supporting you on your journey to improved mental health and well-being.

Who is this intake for?

First name

Last name

Email

Phone number

Birthday

Month

Day

Year

Address

Country/Region

Address

City

Zip / Postal code

Payment Preference

Types of Therapy Needed

Individual Therapy

Diagnostic Evaluation and Medication Management

Couples or Family Therapy

Support Groups and Workshops

Individual Therapy is our primary service and must be selected. Please select any additional service if you or a loved one are in need of these types of treatment.

I understand that this intake document is the first step in the treatment process. Please choose a convenient time for a free 15-minute therapeutic care consultation to match me with the best treatment option.

Schedule an appointment

July 2025