Counseling Appointment- Online Contact | Tender Rock Counseling Center

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 *

Client Birthday *

Client Age *

Is Client Related to Our Existing Client? *

NO

YES; Name?YES; Name?

Contact Name *

Contact Phone

Relationship to the Client

Contact Email Address *

(We will contact you thru this Email to confirm your appointment and setup the Registration process)

What is your primary issues *

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) *

Preferred Schedule Start From *

Preferred Payment Method ? *

What's Your Insurance ?

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

Subscriber's Birthday? *

How did you find us ? *

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.