Waitlist QuestionnairePlease complete the following form to be added to Philip’s waiting list. Thank you! Name of Client * First Name Last Name Parent/Guardian (if client is a minor) First Name Last Name Email * (If client is a minor, put down parent/guardian email address) Phone * (If client is a minor, put down parent/guardian phone number) (###) ### #### Type of Counseling * (Select all the apply) Individual Couples Family Adolescent Method of payment * Insurance Medicaid Private Pay (Cash, Card, Check) Insurance Company (if applicable) Thank you! Philip will reach out to you when there is an opening available.
