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 (12pm - 5pm) on weekdays

During the weekend (Saturday 10am-2pm) (Not available for all therapists)

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

Ja'A Brown - Intern (does not accept insurance - self pay rate only) - offers in-person or Telehealth

Jayme Hendricks, MS - offers in-person or Telehealth

Erika Atkinson, LCSW - offers in-person or Telehealth ages 18 and up (GA/IN)

Derrick Campbell, APC, NCC - offers Telehealth or in-person every other Saturday (WAITLIST FOR SATURDAY APPOINTMENTS)

Alenna Wolmack, MS - offers Telehealth ONLY

Michele Fairconnetue - Intern (does not accept insurance - self pay rate only) - offers in-person or Telehealth

Andrea Futrell, LCSW, LSWIC NOT ACCEPTING NEW CLIENTS (WAITLIST FOR SUN ONLY) - offers in-person or Telehealth

Scarlet Chancey, LPC, LPC-S, LMHC, CPCS, CADC II, ICADC, MATS, ACS NOT ACCEPTING NEW CLIENTS - offers in-person or Telehealth

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