Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

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Select all possible times you are available for sessions (check all that apply). *

During the morning (9am-12pm) on weekdays

During the afternoon (2pm - 5pm) on weekdays

During the evening (5pm-7pm) on weekdays

During the weekend (Saturday 10am-2pm)

Do you have a preference on therapist assigned? If so, please select who you prefer to be seen by. *

Scarlet Chancey, LPC, CPCS, CADC II, MATS, ACS - LIMITED AVAILABILITY (SAT) ONLY - Offers in-person only in GA, Telehealth GA/SC)

Andrea Futrell, LCSW, LSWIC (NOT CURRENTLY ACCEPTING NEW CLIENTS) - offers in-person only in GA or Telehealth only in GA/WA)

Michele Fairconnetue - Intern (offers in-person or Telehealth only in GA)

Derrick Campbell, APC (CURRENTLY ACCEPTING New Clients Starting in February) - offers Telehealth M-F or in-person every other Saturday

Privacy and Security *

I understand that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email can be intercepted and read by other parties beside the person whom it is addressed. I give CAGE Counseling Services permission to contact me via the methods selected below.

I consent to receive an email correspondence.

I consent to receive text messages.

I consent to receive a phone call, OKAY to leave a voicemail.

Consent *

I agree that CAGE Counseling Services LLC., may receive the information above electronically and may communicate with me. I understand that this form is not a guarantee of services. I also understand that email transmissions are capable of being intercepted, and privacy of any confidential information that is sent or received cannot be absolutely guaranteed. I agree to the terms, risks, and limits.

I agree