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 (603) 865-1321.

Please note, we are facing unprecedented demand for mental health services at this time. We will do our best to offer you an appointment as quickly as possible. Our intake coordinators will speak to you about options that will allow for quicker access if there will be a wait time to fulfill your particular request for scheduling.
(* 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)
(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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