Registration, and
Terms of Service
(One form per person.)
This form is for NEW clients, and for those returning more than six months since their last appointment.

Full name*

Cell Phone Number*

Email Address*

Age*

Sex*

Date of Birth*

Home Mailing Address*

City, State, ZIP code*

Employment*

How were you referred? *

Type of Payment (required)*

If using Insurance: Identification Number

Enter your Insurance ID# here

If using Insurance: Subscriber Name

Enter the name of the person who is "Primary" on your policy.

If using Insurance: Relationship to the Insured

Emergency or Alternate contact name and number *

I authorize the following person to be contacted if I am unable to be reached.

Seeking marriage or relationship counseling?

Enter the name of your spouse or significant other if you are seeking marriage or relationship counseling.

Briefly describe the reason you are requesting an appointment.*

(Brief description)

Terms of Service *

I verify that I am the person named, and that I am over the age of 18. I have read, understand and agree to the Appointment and Payment Policies (effective 10/13/2022), and I consent to receive treatment and services from Marney DeFoore, LCSW-S. I agree to receive account management and appointment scheduling information by phone, voicemail, text, email or US Mail (message and data rates may apply). I understand these terms are subject to change.

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Thank you! Your registration and appointment request was sent. Marney will contact you after he reviews your information.

Marney DeFoore LCSW-S

Registration, and Terms of Service(One form per person.)This form is for NEW clients, and for those returning more than six months since their last appointment.

Registration, and
Terms of Service
(One form per person.)
This form is for NEW clients, and for those returning more than six months since their last appointment.