First Name *

Last Name *

Email *

Phone *

Type of Counseling you are looking for *

Briefly describe the issue you would like to work on *

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

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

Child's email and phone (if available) OPTIONAL

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

How would you like to receive services?

Insurance Verification (If you plan to utilize your insurance)

Please select your insurance type. If you do not have insurance or do not want to use insurance, please select "private pay". If you have an insurance listed, select "other".

Name of Insurance *

Is your insurance plan a form of Medicare or Medicaid (AHCCCS), such as United Community Plan, AZ Complete Health, Health Choice AZ or Mercy Care? (we do not accept Medicare or Medicaid)

Member ID

Group ID

Front of Insurance Card (Picture)

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

Back of Insurance Card (Picture)

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

Client's Date of Birth (if you are filling this out for someone else, do not enter YOUR date of birth. We need the client's date of birth.)*

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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