Appointment Form

New Client Appointment Request

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*

First Name Last Name
Date of Birth

MonthDay Year
Date
E-mail*
Phone Number*

Area Code Phone Number
Preferred method of contact?*

EmailPhoneEither
What service(s) are you requesting?*

Individual CounselingCouples CounselingGroup CounselingFamily CounselingChild/Adolescent CounselingReduced fee (grad student intern) counselingAssessment Services for ChildrenAssessment Services for Adults
Custody/Family Information (if patient/client is under 18) *
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: *
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?*
Name of Physician:
Friend/Family/Client Name:
Please describe:
Please Read:*

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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New Client Appointment Request