New Client Form

Please fill out the following information.

Blue Door Counseling will be in touch soon!

Client name

First Name

Last Name

Parent/Guardian if client is under 18

First Name

Last Name

Client date of birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Select payment option

Select insurance/self- pay

Insurance information

Policy id# Name and date of birth of policy holder Insurance company address and telephone number

Presenting concern

Why are you seeking counseling at this time?