Request Appointment - Marriage Counseling Chattanooga

Important Information:

Emergency: If you are having a crisis or emergency please do NOT use this form. Instead please call 911 or go to your nearest ER.
This form creates a request for an appointment - it does not schedule you immediately
We will review your information and contact you within 2 business days
You will receive patient portal access via email to complete intake paperwork
All fields marked with * are required
Privacy: The form is run through secure servers, however, please know that there is no way to secure online forms 100%.

Your Information

First Name

Last Name

Phone

Spouse's/Significant Other's Information:
Please provide your Spouse/Significant Other's Information. (To set up the portal properly, we need a unique email and phone number for each of you. Due to HIPAA privacy laws, this information MUST be different from yours. Our system will not allow the same email and phone number for 2 different people).

Spouse's/Significant Other's Information

First Name

Last Name

Phone

Due to a high number of claims rejections for couples counseling, we ask that couples come prepared to cover the cost of therapy. Please indicate that you understand that couples counseling is an out of pocket expense (cash, credit card, check). Regular session fee is $110 during business hours, or $135 for evening/weekend appointments.

Yes, we understand the above statement

Please describe the reason you're seeking counseling. (This information is used to help determine "goodness of fit". Although we would love to help everyone, we need to prioritize those who need help in the areas in which we have the most expertise and experience.)

Your information is confidential and secure. By submitting this form, you agree to our privacy practices.

Request a Couples Counseling Appointment

Your Information

Spouse's/Significant Other's Information