This form is to identify and ensure that our agency is a good fit for your therapeutic needs. This is NOT a guarantee of services. All collected data is HIPAA protected and encrypted with only Release it Counseling having access to this data. 

 

• All questions with a red asterisk must be completed, if it doesn't have a red asterisk just click "next".

• Please make sure you thoroughly complete all questions, if not you may risk your intake not being reviewed by clinical director. Please ensure your insurance info is entered correctly to prevent a delay in scheduling.

• Allow up to two business days for our clinical director to review your submission (often reviewed in the same business day). Please monitor your email for an email from "INFO@RELEASEIT757.com" for the proceeding steps after throughly submitting this form.

• You may receive an email from "SIMPLEPRACTICE.com" after completing this form, to register your online portal; if you do please complete your registration for scheduling.