Graceful Counseling Center PLLC

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Date of birth

Gender

State

Select the state you live in

Reason for care

What type of therapy are you seeking?

Couples/Marriage Therapy Individual Therapy Family Therapy Christian Counseling Child/Teen Therapy

Billing & Payment

Payment method

How do you plan to pay?

If using insurance, what is your insurance provider?

Please provide provider and insurance plan information. If not using insurance put NA or Not Applicable

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Client Preferences

When are you generally available for appointments?

Please list the days and general time ranges you are available for appointments. For example: Monday 5–8 PM, Tuesday 9 AM–12 PM, Wednesday unavailable, Thursday after 4 PM etc. This information helps determine whether our schedules may be a good fit. Sharing your availability does not guarantee that an appointment will be available during those times.

Limited to 600 characters

Preferred modality

Please select your preferred way to attend therapy. Sharing your preference does not guarantee that an appointment will be available in that modality.

In-person Telehealth No Preference

Is there anything that the clinician needs to know?

Please briefly share what brings you to therapy or what bringing you to therapy

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.