Counseling Appointment Request

To request an appointment with a JFS specialized therapist, please complete the form below.

Once the form is submitted, our intake coordinator will contact you within two business days to complete all required paperwork. (Please note: Our counseling office hours are Mon – Thurs 8am – 5pm, excluding holidays). Once your paperwork is completed, a therapist will be assigned to you based on your specific needs and the therapists specialization and availability.

(If you would prefer to request an appointment on the phone, please call (407) 644-7671)

First Name

Last Name

Are you requesting this appointment only for yourself?

Yes No

If no, list the other individual's full name and relationship to the applicant below.

Please note: You may only request an appointment for yourself or on behalf of your child (age 17 and under), your client if you are a provider, or your partner if inquiring about couples therapy. All other requests must be completed by the client seeking counseling themselves.

Client Date of Birth

Phone

Preferred Form of Communication

Email Phone

Insurance Provider

Insurance ID #

Appointment Availability

Please enter a few days of the week and times you are available and we will do our best to find a time that works.
Please note: Friday and Saturday appointments are very limited.

Type of Therapist Preference

Please list any preferred therapist specialties or qualities. Although some therapists might have full case loads and are not accepting new clients, we will do our best to accommodate your request.

Area of Concern

Please describe the reason for which you are seeking a counseling appointment.

How did you hear about us?

Please note: This form is not a means to communicate directly with a therapist.

If this is an emergency, please call 911.

Counseling Appointment Request

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