Professional Referral Request an Appointment

Request an Appointment - Mississippi

Note: This form should not be used in the case of urgency or emergency. If this is an emergency, please contact 911 or proceed to your nearest emergency room.

Please use this form to request an initial appointment. Your request will be directed to our Intake Coordinator. We will respond as soon as possible and within one to two business days.

If you do not hear back from us in that window of time, please contact our office at (601) 699-4080.

(* required info)

Clients First Name *

Clients Last Name *

Date of Birth * (mm-dd-yyyy)

Street Address*

City *

State *

Zip *

Parents Name (if Client under 18)

Phone *

(do not include 1- prefix)

OK to Leave Message *

Yes No

E-Mail Adr

Insurance Carrier *

Secondary Insurance

ID Number

Location Preference

Hattiesburg Telehealth

Alternate Location Choice

Hattiesburg Telehealth

Reason for Appointment *

Schedule Availability

Does client have any have any current or historical concerns with substance use? *

Yes No

How did you hear about our practice? *

If you were referred to Counseling Associates, who referred you?

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(603) 865-1321 NH / VT

(601) 699-4080 MS

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Counseling Associates of New London, Claremont, Hanover, Upper Valley, and Plymouth, NH : coming soon to Concord and Keene
Counseling Associates of Hattiesburg, MS

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