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Service:EMDR Session add another, change
Staff: Frank Geis, MA, LMFT, LPC, CSAT, CPTT change
Date/time:Thu, Apr 25 at 8:00 AM (CDT) change

Thank you for setting a counseling appointment with New Directions Counseling & Wellness Center.  We look forward to seeing you.
Please do not submit any Protected Health Information (PHI)

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First name*
Last name*
Email*
Phone*
Street address*
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Birthday
Employer and Position
Marital Status*
Emergency Contact; Name & Contact Number
Responsible Party
If other, list Name, Employer, Contact Number & E-mail Address
For Minors only: School Name & Grade
For Minors only: Are Parents Divorced?
If Divorced - According to the Divorce Decree who is allowed to seek treatment on the Minor's behalf?
Please Note a copy of the Divorce Decree declaring guardianship MUST be on file before the child can be seen.
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