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How We Can Help
Adults
Children & Families
Teens
Couples
Substance Use
Medication Services - NH/VT
Groups
School Services
Groups
Getting Started
Getting Started
Request an Appointment
Client Forms
About Us
Information for Clients
Our Therapists
Locations
Contact
Careers
Client Portal Access
For Professionals
Providers
Professional Referral
Join Our Team
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
Please choose yes or 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
Please choose yes or no
How did you hear about our practice?
*
If you were referred to Counseling Associates, who referred you?
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