WEB REF

New Client Inquiry
Thank you for your interest in Counseling Centers of North Puget Sound.

You may use this form to send us a message about a a possible new client appointment. We are happy to help you find the help that is right for you.

All information entered into this form is securely transmitted and stored, for your protection. YOUR INFORMATION IS CONFIDENTIAL, except when we are required by law to disclose information. For more information, see our privacy policy. We NEVER sell your information to anyone.

Professionals: Make a referral here.

USING THIS FORM:

This is for non-emergency new client appointment requests. If you are contacting us about someone who is in need of immediate help, please contact your local crisis line or seek emergency assistance.

More information is better. Especially regarding office locations and hours/days you are available/not available,

* We have one psychologist who provides autism evaluations: Ann Uherek, PsyD. Contact her directly to discuss possible appoiments at 206-729-2101. We are unable to forward these requests to her.

Dr. Uherek is only providing evaluations currently, except for current and former clients for pscyhotherapy.

CONTACT INFO:

Please enter your information, even if you are contacting us about someone elese.
WEB REF
Date

MonthDayYear
Date
Name of Contact:
Best Phone number to reach you:
Is it okay to leave a detailed message at this number?*
Your email address:
example@example.com
Is it okay to send you a detailed message?
You have chosen to restrict messaging from us. We respect your choice. However, we likely will not be able to personally let you know what we have done with your request.

Instead, you can generally expect: After we have reviewed the request, we will forward it to the clinicians who may be a good match.

If someone has an opening that may work, they will reach out directly via phone, within a week.
If a clinician has an opening, they will contact you via phone or email, based on the clincian's and your preferences. Allowing us to contact you by email is strictly voluntary. PRIVACY: Consider your privacy when choosing an email address to use on this form. If you give us permission to send a detailed email message, then we will send you a message: 1) to let you know that we have received your request, 2) have sent the request to our providers, 3) provide additional information, and/or 4) to follow up if needed. CCNPS has no control over the privacy of email once it arrives in your inbox. *****You accept responsibility for the privacy of the email messages held in your email account or device. ******

I have read, and agree to the CCNPS email policy.
WHO ARE YOU CONTACTING US ABOUT?
I am contacting you about:
The person's name:
Age of the person:
Gender:

CONCERNS:

Please give us some information so we can find the best match.
What are your main concerns that brought you to counseling?
What else would you like us to know about the situation? (more info is better)

APPOINTMENT PREFERENCES:

IMPORTANT TIP: Later afternoon/evening appointments are often full. To ensure the best chance of finding a suitable match for your request, include as many options as possible for days and times that may work for your appointments.
What days to you prefer for your appointments: (choose all that apply)

MonTueWedThurFriSatSun
Comments about appointment days:
What times do you prefer for appointments:
When are you NOT available?

New Client Inquiry

CONTACT INFO:

WHO ARE YOU CONTACTING US ABOUT?

CONCERNS:

SERVICES:

LOCATIONS:

APPOINTMENT PREFERENCES:

FINANCIAL: