Schedule My First Visit

4100 McEwen
Suite 285
Farmers Branch, TX 75244
Phone: 972-820-9965
Fax: 866-278-4727
counselor@northdallascounselor.com

Monique Thompson, LPC & Associates

Schedule My First Office Visit

Welcome. New Patients wanting to schedule their first office visit will want to complete and submit this form.

After you submit this form our office will prepare for your 15 minute phone consult with a counselor. If the consult has not yet been scheduled, we will email you to set up your free, 15 minute phone consult with a counselor.

First and Last Name:
Street Address:
City, State and Zip Code:
Phone Number:
Is it okay to leave detailed messages at this number		yes no
Email Address:
Is it okay to contact you by email		yes no
Date of Birth:
Have you scheduled your 15 minute phone appointment? If not, we will contact you right away by email to set on up.		yes no
How soon do you want to schedule your first office visit:
What are the best times of day and days of the week for you to meet?:
Please indicate the type of counseling you are looking for (optional):
Preferred Counselor:
Preferred Location:
Are you planning to use insurance?:
INSURANCE		If you are thinking of using insurance, complete questions 1-5.
1. Insurance Carrier:
2. Member ID:
3. Group Number:
4. Phone Number for Mental Health:
5. Phone Number for Customer Service:
Additional Information/Comments: