If you are interested in becoming a client at Redefined Counseling and Consulting, complete the following form and a staff member will get back to you via email within 2 business days. Client's First Name *Client's Last Name *Client's Birthday *Name of person completing the form if different than clientStreet Address *Apartment, suite, etcCity *State *ZIP / Postal Code *Phone Number *Adult/Client Email Address *Adolescent's Email Address (14+ years old)General Information About Why You Are Seeking Counseling Services At This Time *0 / 1000Referred By *SelfOtherReferred By NamePreferred Provider *Please select one or more preferred providers.Alicia Blackley, LPCC-S [Not currently accepting clients]Tammy Cappadonna-Kloss, LPCC-S [Not currently accepting clients]Amilia Teren, LPCC [Virtual only]Bonita Tyree, LPCCarmen Holmes, LPCCarolyn Chambers, MEd, LPCC-S, LCDC [Virtual only]Dusty Timmons, LSC, LPCEmilene Shibley, PsyDJamie Onion, CTKaitlyn Gerhardt, LPCC-S [Virtual only] [Not currently accepting clients]Katy Flegal, LISW, LICDCLisa Kostansek, LPCC-SLogan Ross, MA, CTRS, LPCMarissa Hadney, LPCCMichelle Paluf, LPCNellie Goldberg, CTYael Schwartz, LPCCLocation of Appointment *In-person counselingVirtual counselingOpen to either in-person or virtualZest (Referral necessary)Available Days for Appointments *MondayTuesdayWednesdayThursdayFridayAvailable Times for Appointments *8am - NoonNoon - 4pm4pm - 7pmInsurance or Self-Pay *InsuranceSelf-PayInsurance Company Name *Policy Holder's Name *Policy Holder's Birthday *Insurance Member ID# *Insurance Group ID *In order for Redefined Counseling and Consulting to verify your insurance benefits, images of the front and back of your insurance card must be uploaded to this document prior to submitting.Front and Back of Insurance Card *Maximum file size of 15MB eachDrag and Drop (or) Choose FilesSubmit
