Name * First Name Last Name Email * Phone * (###) ### #### Age of Person Seeking Counseling * Under 18 18-40 40-50 50+ Insurance Provider * Blue Cross Blue Shield Blue Care Network Aetna Priority Health United Healthcare Private Pay Reason for Seeking Counseling * check all that apply Addiction ADHD Anger Management Anxiety Autism Bipolar Disorder Borderline Personality Disorder Depression Eating Disorder Grief Infertility Pregnancy/Postpartum Relationship Issues Self-Esteem Trauma Other How did you hear about Clark Counseling? * Online Search Friend/Family Member Instagram Church University/College Doctor's Office Psychology Today Other (please let us know in your message) Preferred Method of Contact Email Text Message * Thank you for reaching out to Clark Counseling. Inquires will be responded to within 24 business hours via email. Get in touch. Ready to schedule an initial appointment? We’d love to hear from you. Please fill out this form and hit send. Inquires will be responded to within 24 business hours via email.
