NEW CLIENT REQUEST | Steadfast Counseling

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NEW CLIENT APPOINTMENT REQUEST

Briefly describe what you are seeking counseling for.

Select a Service

First and Last Name

Address

Birthdate

Phone

Email

Authorizatons and Communication Preferences * Required

I give Steadfast-Counseling permission to contact me via text.

I give Steadfast-Counseling permission to contact me via email.

I prefer to communicate via text.

I prefer to communicate vial email.

I prefer to commuinicate via phone.

Insurance Provider and Member ID

Thank you! I will reach out to you shortly.

LOCATION

CONTACT

NEW LOCATION

1914 Thomes Ave.

Cheyenne, WY 82001

Tel: 307-222-2157

Simple Practice Client Portal

https://todd-scott.clientsecure.me

PRIVACY NOTICE-This contact form is to provide Steadfast-Counseling with information to contact you for the purpose of scheduling. Please do not include any information in this form that would be considered protected, private, or confidential. This form is not appropriate to use if you are in crisis.

Thank you for your interest!

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