Client Appointment Request

Personal Information Notice

Please be aware that communicating personal information electronically poses a risk to your confidentiality. New Story Behavioral Health uses HIPAA-compliant electronic communication to protect your privacy. New Story Behavioral Health Staff will not disclose any personal information provided on this application form.

First Name

Last Name

Your Date of Birth

Phone Number

Please enter a valid phone number. Format: (000) 000-0000.

Can we leave a voice message at this number?

Yes No

Text Messaging Opt-In (SMS Opt-in). By checking this box, I consent to receive SMS (text messages) from New Story Behavioral Health. At any time, you may reply STOP to opt-out or Reply HELP for support. Message & data rates may apply. Messaging frequency may vary. Visit https://www.newstorybehavioralhealth.com/privacy to see our privacy policy and Terms of Service. SMS consent and phone numbers will not be shared with any third parties or affiliates.

Our full privacy policy is located here:

https://www.newstorybehavioralhealth.com/privacy

Email Address

We would like to keep you informed of events and services offered by New Story Behavioral Health. Check here to consent to receiving information via email. Emails will be sent to your inbox as standard, unsecured (unencrypted) email. Please take appropriate care to protect your personal privacy. You can unsubscribe from emails at any time.

Yes, keep me informed. No, thank you.

Please list your city and state of residence.

City and state are required. Street address and postal code are optional.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Are you seeking services for yourself or someone else?

Myself My Child (Under 18) Someone Else

Name of Your Child Under 18 - First Name

Name of Your Child Under 18 - Last Name

Birthdate of Your Child Under 18

Name of the person for which you seek services - First Name

Name of the person for which you seek services - Last Name

Gender of the person seeking services

What services are you seeking?

Psychiatric/Medication Individual Counseling Individual Intensive Couples/Marriage Counseling Couples/Marriage Counseling Intensive Family Counseling Equine-Assisted Psychotherapy Confessional Communities™/Group Counseling Consultation

Other mental health resource (please list below)

Other

I am interested in reduced-fee services with a New Story Behavioral Health intern.

Yes! Tell Me More Not at this time

Comments/Reason for Services

New Story Behavioral Health will review your request and follow up with the next step.