Request an Appointment
At HeartLife we exist to facilitate Gospel hope and healing with clinical excellence in a professional therapeutic setting.
New Client Scheduling
If you would like help finding the right counselor, please fill out the form below. Once complete, our front desk staff will contact you to set up your appointment. You can also reach us at (901) 756-5788 to get scheduled.
Client Full Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
E-mail
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Phone Number
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Area Code
Phone Number
Preferred method of contact?
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Email
Phone
Either
What service(s) are you requesting?
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Individual Counseling
Couples Counseling
Group Counseling
Family Counseling
Child/Adolescent Counseling
Reduced fee (grad student intern) counseling
Assessment Services for Children
Assessment Services for Adults
Custody/Family Information (if patient/client is under 18)
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Parents are married
Parents are divorced, Joint Custody
Parents are divorced, One Parent has decision-making authority
Parents Never Married
We will ask you to provide documentation of custody if parents do not both agree to participate in therapy/counseling.
What days/times are you available?
Reason for counseling or testing:
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Please provide any info we may need to best connect you to a counselor. If appt is for multiple people, please note how many.
How did you hear about HeartLife?
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Referred by friend/family
Referred by Doctor/Physician
Internet Search
Social Media
Other
Name of Physician:
Friend/Family/Client Name:
Please describe:
Please Read:
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I understand HeartLife is private pay does not have relationship with insurance or Managed Care Companies. Please visit our website to learn more.
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Request an Appointment
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