Appointment Form

Appointment Request Form

Thank you for your interest in Cultivate Counseling & Consulting. We appreciate you taking the time to complete our Appointment Request Form.

Please provide the information below so our team can better understand your needs and determine the best next steps. Once your request has been reviewed, a member of our team will contact you to discuss availability and schedule your first appointment.

We look forward to connecting with you!

Is this appointment for you or someone else?

Myself

Someone else

Please note: If the client is under 14 years old or you are seeking Couples Therapy, please call our office at (234)571-4046 to confirm availability before submitting an appointment request.

I acknowledge that I have read this.

I am seeking:

Individual Therapy

Couples Therapy

Family Therapy

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Phone Number

Client Information

Client's Legal First Name

Client's Legal Last Name

Name the Client Goes By

Email Address

Phone Number (Please note that we will not use your phone number to opt into text messages, but it is required to call to schedule your first appointment).

Date of Birth

Month

Day

Year

Preferred Appointment

In-Person or Telehealth preference?

Do you have insurance?

Yes

Clinician Preference

Clinician Request/Preference: You may request a specific clinician or select "No Preference." We will do our best to accommodate requests, but clinician availability may vary.

Dustin Smith, LSW, Individual Counseling

Nick Maricic, LPC, Individual Counseling

Samantha Grey, LSW, Individual Counseling

Ravnit Magnat, CT, Individual Counseling

Ashley Bailey, CT, Individual Counseling

Rekita Adams, CT, Individual Counseling

No Preference

How did you hear about us?