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Starting as a New Client

New Clients are Welcome at TY

Thank you for your interest in becoming a client with TY & Associates Counseling.

To protect your privacy, the form below is only to help us get you started as a client. Following the review of your information by our staff, we will contact you with the remaining forms to complete your pre-appointment registration.

We look forward to seeing you soon.

New Client Registration

Client Last Name *

Client First Name *

Checkboxes

Client is a Minor

Parent/Guardian Last Name *

Parent/Guardian First Name *

Phone *

Email *

Payment Options *

In-Network Providers *

NOTE: Any charges not covered by insurance will be the responsibility of the client or the client's responsible party.

NOTE: If your insurance provider is not listed, please verify your out of network benefits before scheduling an appointment. Charges not covered by insurance will be the responsibility of the client or the client's responsible party.

NOTE: Self Pay Rates start at $110/50 minute session. Payment is due at time of session.

Preferred Day *