Evergreen Counseling and Wellness

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

State

Select the state you live in

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Administrative

How did you hear about Evergreen Counseling and Wellness?

Reason for care

What brings you to our practice right now?

(A few sentences is perfect.)

Anything else you want to share before we connect?

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.