Registration

Please use one form per person.
If using an insurance policy, ensure the information below matches your Identification card.

Full name*

Cell Phone Number*

Email Address*

Age*

Sex*

Date of Birth*

Home Mailing Address*

City, State, Zip Code*

Place of Employment*

How were you referred? *

Type of Payment (required)*

If using Insurance: Identification Number

If using Insurance: Subscriber Name

If using Insurance: Relationship to the Insured

Emergency or Alternate contact name and number *

Seeking marriage or relationship counseling?

Briefly describe the reason you are requesting an appointment.*

By submitting this form below, I confirm that I am over the age of 17, that I have read and agree to

the Appointment and Payment Policies, consent to receive treatment and services from Marney DeFoore, LCSW-S,

allow the release of my billing information necessary to process and manage claims, and

authorize communication by phone, text, email, or U.S. Mail, understanding message and data rates may apply.

I also understand that fees and terms are subject to change.

Marney DeFoore LCSW-S