Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Sex *

Male

Female

Prefer not to say

Type of Counseling *

Individual

Couples/Marriage

Family

Pre-Marital

Have you had counseling in the past? *

Yes

No

Marital Status *

Single

Married

Divorced

Widowed

Prefer not to say

Were you referred to by an outside organization that is taking on all or part of the financial obligation? ie: church, non-profit *

Yes

No

The cost for a 50-minute session is $90.00. Buxmont Counseling does not accept insurance directly, however, your insurance plan may offer reimbursement for our services. Additionally, if you have a Health Savings Account (HSA) or Flexible Spending Account (FSA), Buxmont can often be approved as a payee or provider. *

I have read & understand.