Connect Counseling

New Client Inquiry Form

We're eager to contact you for an opening with one of our wonderful therapists. Please provide the following information so we can match you with an appropriate fit. We look forward to serving you!

*Completion of this form does not indicate an agreement to provide therapy services or make you a client of Connect Counseling Center, LLC. Opportunity times can vary drastically based on therapist availability and current inquiry list length.

Full Name of Client *

If client is a minor, please provide full name of legal guardian.

Please specify if this is for Individuals, Couples, or Family Therapy. If Family, please list names and ages for each participant. *

Client Date of birth *

Contact Number *

Contact Email

Contact Method Preference *

Phone Call

Text Message

Email and text message exchanges are not necessarily HIPAA compliant. By selecting below, I understand and assume the risks of choosing to communicate via either of these methods. *

Agreed

Disagree

Please select which location you prefer (choose all that apply)

Mt. Juliet

Clarksville

Cookeville

Virtual / Telehealth

We offer both in person or virtual counseling services. Please specify if you have a preference. *

In Person

Virtual

Both

*Virtual services can only be provided within the state that the therapist is licensed in. For Connect Counseling Center, these services can only take place within the Tennessee border.

Some providers at Connect accept the following insurances. If you're covered under any insurance that you'd like to use, please check any that apply. If you're interested in self-pay options if available sooner, please answer the self-pay question below as well. *

Tricare

Blue Cross Blue Shield

United Healthcare

Aetna

Cigna

Open to self-pay options (Rates vary)

In order to help us match you with the right fit, please provide a brief description of why you are seeking services.

*All adults in the US are mandated reporters and any disclosure of abuse or harm to self or others will have to be reported.

How did you hear about us?

What is your billing address? *

Email Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Connect Counseling Center therapists and/or office staff communicating with me via email or text message