First Name *

Last Name *

Phone *

Email *

Address *

Postal code *

Type of Counseling you are looking for

Your partner’s full name, phone number & email (if you are seeking couple or sex therapy)

Child's Name and Age (if you are seeking child and teen therapy)

Child's email and phone (if available)

Insurance Verification (If you plan to utilize your insurance)

Please be informed that we are not contracted with any Medicare or AHCCCS plans such as United Community Plan & Health Choice

Name of Insurance

Member ID

Group ID

Date of birth of requesting client

Front of Insurance Card (Picture)

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Back of Insurance Card (Picture)

(click to upload | .png, .jpg, .jpeg only)

How would you like to receive services?

Briefly describe the issue you would like to work with

Would you like first availability or work with a specific clinician? *

What’s the best way to contact you?

How did you hear about us?

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 Wiser Counseling therapists, providers, and/or office staff communicating with me via email or text message.

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