Health Insurance Pre-Enrollment Form Name Email Address Phone Address City State Zip Code Policy Holder Date of Birth Health Insurance Carrier Name Policy Holder Name Name of Client Client Date of Birth (Person Receiving Counseling) Policy Number of Client Gender Preference of Counselor (Male/Female/No Preference) Gender Preference of Counselor (Male/Female/No Preference)MaleFemaleNo Preference Preferred Days/Times of Appointment (M-F 8am to 4pm, M-F 5pm-9pm, Sat 8am-9pm) Preferred Days/Times of Appointment (M-F 8am to 4pm, M-F 5pm-9pm, Sat 8am-9pm) M-F 8am to 4pm M-F 5pm-9pm Sat 8am-9pm What type of counseling are you seeking? What type of counseling are you seeking?Marriage counselingPre-marital counselingIndividual counselingFamily counselingChild counseling Briefly describe your reason for counseling (this will help us place you with a counselor more quickly) Other Notes Submit