New Patient Forms
General Information
Scheduling an Appointment
Please use our online calendar to make an appointment IF you have been through the intake process. If not, please complete the NEW CLIENT form and wait for a response from our staff before making your first appointment.
Payment
Our fees range from $80 – $165. Please see the FAQ page or call for more information.
We work with many insurance companies and are willing to bill them as a courtesy to our clients. Clients are responsible only for the co-pay or deductible amount the insurance company sets. We do NOT charge clients any fees above the insurance rate for companies we contract with.
Cancellation Policy
Appointments must be cancelled 24 hours in advance. Missed appointments and cancellations made less than 24 hours in advance result in a $75 charge for the counseling session which IS NOT COVERED BY INSURANCE even if we have a contract. THIS IS AN OUT OF POCKET EXPENSE and must be paid before you schedule your next appointment. Please be courteous and cancel if you can't make it.
Forms
To save time before your first appointment and to maximize time with your therapist, please complete the forms that are to the right (Adult Intake, Insurance, Client's Rights, and No Show). Please note, the intake forms are lengthy and in depth. The goal is NOT to assist you in writing a book. It is to collect as much information as possible to help your therapist make the best diagnosis and treatment plan.
Please use our online calendar to make an appointment IF you have been through the intake process. If not, please complete the NEW CLIENT form and wait for a response from our staff before making your first appointment.
Payment
Our fees range from $80 – $165. Please see the FAQ page or call for more information.
We work with many insurance companies and are willing to bill them as a courtesy to our clients. Clients are responsible only for the co-pay or deductible amount the insurance company sets. We do NOT charge clients any fees above the insurance rate for companies we contract with.
Cancellation Policy
Appointments must be cancelled 24 hours in advance. Missed appointments and cancellations made less than 24 hours in advance result in a $75 charge for the counseling session which IS NOT COVERED BY INSURANCE even if we have a contract. THIS IS AN OUT OF POCKET EXPENSE and must be paid before you schedule your next appointment. Please be courteous and cancel if you can't make it.
Forms
To save time before your first appointment and to maximize time with your therapist, please complete the forms that are to the right (Adult Intake, Insurance, Client's Rights, and No Show). Please note, the intake forms are lengthy and in depth. The goal is NOT to assist you in writing a book. It is to collect as much information as possible to help your therapist make the best diagnosis and treatment plan.
Coming For Your First Appointment?
Intake Form
Please complete this intake form as fully as possible. This form will help your therapist determine how best to help you. Please note there are separate forms for adults and children. You may complete the form here, online. Please be aware the completed form will be e-mailed to wilburncounseling@protonmail.com and though we take every precaution, e-mail is not always a secure means of communication. If you'd rather print and complete the form, you may drop it off at the Island City Baptist Church (office location) in a sealed envelope. A locked mailbox is located at the back door of the church (the entry door for Renew Counseling). All forms MUST be submitted BEFORE your first appointment.
Click Here - Fill and submit Potential New Client form
Click Here - Fill and submit Adult Intake Form online
Click Here - Download Adult Intake Form
Click Here - Fill and submit Teen Intake Form online
Click Here - Download Teen Intake Form
Click Here - Fill and submit Potential New Client form
Click Here - Fill and submit Adult Intake Form online
Click Here - Download Adult Intake Form
Click Here - Fill and submit Teen Intake Form online
Click Here - Download Teen Intake Form
Insurance Form
Client Rights & No Show Policy