Schedule a Counseling Appointment

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

If you do not have insurance, please indicate below: I do not have insurance

For those clients with insurance, please complete the following information:

Primary Insurance Provider Please enter valid data.

Member/Policy # Please enter valid data.

Group # Please enter valid data.

Insurance Company Phone Number Please enter valid data.

First & Last Name of Insured Please enter valid data.

DOB of Insured Please enter valid data.

If you have secondary or supplemental insurance, please provide the information below:

Secondary Insurance Provider Please enter valid data.

Member/Policy # Please enter valid data.

Group # Please enter valid data.

Insurance Company Phone Number Please enter valid data.

First & Last Name of Insured Please enter valid data.

DOB of Insured Please enter valid data.

CLIENT INFORMATION

Client First & Last Name REQUIRED Please fill out this field. Please enter valid data.

Client Date of Birth REQUIRED Please fill out this field. Please enter valid data.

Preferred Location REQUIRED

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Dubuque Waterloo Ames Cedar Rapids Telehealth Please fill out this field.

Seeking Treatment For: REQUIRED

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Individual Adult (Self) Individual Child Couple Family Please fill out this field.

How did you hear about Counseling at Catholic Charities? REQUIRED

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Family/Friend Internet Search Parish Referral Medical Provider Referral Community Agency Other Please fill out this field.

Additional Information

Counseling Appointments