Request An Appointment Schedule an Appointment Personal InformationName* First Last Date* Date Format: MM slash DD slash YYYY Phone*You will receive a text confirmation once we have responded to you via email. You can expect a response within a 24 hour period.Email* We will respond to your request via email within a 24 hour period. If not in your inbox, please check junk/spamHow did you hear about JHFS?* Returning Client Web Family/Friend recommended JHFS Medical Referral Therapy RequestsI am seeking:* Individual Therapy Couple's Therapy Family Therapy Couple Intensive Retreat I have the following insurance:* BlueCross/BlueShield Other None - self pay JH Mental Health Initiative PreScreening* Domestic Violence is/has been issue Substance use/abuse/addictions is/has been an issue for me Affair is recent/historic in relationship None of these apply Reason for seeking counselingPlease briefly describe the reason you are seeking counseling today.Please specify best schedule days/times.*We will do our best to accommodate your requests. Due to increased demand for scheduling, some appointment days/times and/or therapist requests may not be available. We appreciate your patience in scheduling.Thank You for contacting JHFS with your counseling needs.You will hear from us via email, within 24 hours, outlining additional information and scheduling options that best match the days/times you have requested with our current scheduling availabilities.
