First Name *

Last Name *

Phone *

Email *

Address *

Postal code *

What type of mental health services are you seeking? *

Whom Are You Seeking Counseling For *

Briefly describe the issue you would like to work on. *

What insurance do you have? Please note: if your insurance does not appear in this dropdown, we are likely not in-network. *

Client date of birth *

Insurance ID

Front of insurance card (Please provide a picture of your insurance ID if planning to use insurance)

Back of insurance card (picture)

What's the Best Way to Contact You? *

How did you hear about us? *

Email Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Utah Center for Psychology Services therapists and/or office staff communicating with me via email or text message