New Client Waitlist — Katie Vines, LPC

Request a new client appointment

If you are interested in becoming a client please fill out the form below. Make sure to include your email address as that is most likely how we will contact you. Thank you so much for your interest in my practice! At this time, I am typically able to get new clients in within 4 weeks, depending on my availability. Once we receive your request, we will be in touch regarding scheduling.

Name

First Name

Last Name

Client's Email

Client's Phone Number

(###)

###

####

Date of Birth

MM

DD

YYYY

If you feel comfortable doing so, please give a brief explanation of why you are seeking counseling

Who referred you to Katie?

Filing Insurance? If YES please fill out information below.

Name of Insurance Company

Insurance Policy Number

Insurance Group Number

Insured's Name (if different from client)

Insured's Date of Birth

MM

DD

YYYY

Insured's Address

Request a new client appointment

vINES COUNSELING