Name * First Name Last Name Date of Birth MM DD YYYY If Minor, Guardian Full Name Email * Phone * Country (###) ### #### Are you located in the State of Florida * Yes No Who is the appointment for, if not self, please list relationship? * Best day/time to reach you? * Which service are you interested in? * Individual Counseling Couples Counseling Family Counseling Group Counseling Telehealth * Yes No In Office * Yes No When would you like to book your first appointment? * Next Available Appointment Within A Week Within The Next 2 Weeks Other How did you find/hear about Better Me Counseling LLC * Do you have insurance * Yes No If you are using insurance, please add Name, Member ID, and Group Number Thank you! Book a session.
