Counseling Inquiry Name * First Name Last Name Email * Phone Number * (###) ### #### Age * Age of the person seeking services Method of payment * If using insurance, please enter name of insurance company below Private pay Insurance Insurance company (if applicable) Preferred day(s) for weekly therapy: * Monday Tuesday Wednesday Thursday Friday Preferred time(s) for weekly therapy: * Morning Afternoon Do you hope to attend therapy: * You may choose one or both options In person Virtually How can we help? * Explain your main interest in contacting the Martin Center for Integration (marriage counseling, individual therapy, etc.) and anything you'd like us to know about you. Thank you for your interest in counseling services with the Martin Center for Integration.Registration for new clients will resume after the Christmas holiday, on January 15, 2024. We look forward to responding to your inquiry at that time.