Future Client Intake Form

Thank you for being here! We recognize the courage it takes to begin your mental health journey and appreciate you choosing our office. At Healing Hearts Counseling and Consulting, we offer person-centered care focused on building connection, awareness and wholeness in everyone.

Please complete the form below and our administrative team will contact you. Feel free to call our office at 804-556-1436 if any questions arise. We can also complete the intake process over the phone.

First name

Last name

Phone

Mailing Address

Address is needed for insurance purposes only. We will call to obtain policy information and only utilize information shared for your confidential patient portal.

Birthday

Month

Day

Year

new / prospective clients: please provide a birthdate. this helps expedite the scheduling process for insurance purposes.

Availability Preferences

please provide dates and/or times that work best with your current schedule.

this helps our office to coordinate time with counselors efficiently.

Would you like in person or virtual appointments? (select both if you're flexible)

In person

Virtual

please check all that apply

Reasons for Inquiry:

please provide context about your inquiry; be as detailed as you're comfortable with. this helps our office best understand how we can help you.

Preferred Counselor