Counseling Appointment Contact Form (This Contact Form is for the new clients to make appointment only) * Required Field Urgency of Counseling Need * 0 1 2 3 4 5 6 7 8 9 10 0=Not Urgent at all, 10=Extremely Urgent Client Legal Name * Client Gender * MaleFemale Client Birthday * Client Age * Is Client Related to Our Existing Client? * NO YES; Name?YES; Name? Contact Name * Contact Phone * Relationship to the Client * MyselfSpouseParentChildLife PartnerOther Relationship Contact Email Address * (We will contact you thru this Email to confirm your appointment and setup the Registration process) What is your primary issues * ADHDChildhood TraumaCouple /Marital IssuesEating DisordersDepression / AnxietyGrief & Loss / Divorce IssuesFamily IssuesAbusePTSD Describe Issues for Counseling * (Briefly describe issues for which you are seeking counseling) Preferred Schedule Day-ML(select one or more) * Anyday Thursday Friday Preferred Schedule Time-ML (select one or more) * Anytime 08:00-09:00 09:00-10:00 10:00-11:00 11:00-12:00 12:00-13:00 13:00-14:00 14:00-15:00 15:00-16:00 16:00-17:00 17:00-18:00 Preferred Schedule Start From * This WeekNext Week2 Weeks Later3 Weeks Later Preferred Payment Method ? * Don't have Insurance, Self-payHave Insurance but Self-payInsuranceNo preference What's Your Insurance ? * AetnaAnthemBlue Cross Blue Shield (BCBS)Kaiser (PPO / Option)Kaiser (HMO / Core)LifeWise of Washington & OregonPremera Blue CrossRegence Note : Mark Liu is not in Network with Molina Insurance The Insurance ID Number? * The Insurance Group Number? * The Insurance Subscriber Name? * Subscriber's Relationship to the Client * MyselfSpouseParentChildLife PartnerOther Relationship Subscriber's Birthday? * How did you find us ? * Referral by Insurance Co.Psychology TodayGoogle SearchYahoo SearchBing SearchOther Search EngineFacebookYelp / Google+ / Blog / Other internet sourceReferral by other providerFamily Member / FriendTender Rock Counceling Team ReferralI am the returning client Additional Information (If needed) Tender Rock Counseling will require that you provide a credit card on file with our office. * I will agree to sign the " Credit Card on File Policy". (Credit Card on File Policy, please refer to https://tenderrockcounseling.org/credit-card-on-file-policy/) Tender Rock Counseling provides online counseling only. * I agree to do online counseling ***** IMPORTANT NOTICE ***** It has brought to our attention that some e-mails we send out may go to recipients’ Junk Mail folder due to different reasons. We suggest you to check your Junk Mail folder regularly to assure our uninterrupted communication, also please whitelist our email by adding our email domain name “tenderrockcounseling.org” to the list of your Safe senders. Thank you. If you are human, leave this field blank. Δ Tender Rock Counseling– Non Profit Organization | Counselors with Christian FaithBellevue / Eastside, Washington
