GET STARTED

Take the first step by completing the

Preliminary Referral Form.

Getting started with counseling has never been easier.

Submit our 100% online preliminary form to help us determine if our services are the right fit for you.

If you qualify, we’ll connect you with a provider and create a personalized treatment

plan tailored to your needs and goals.

First Name *

Last Name Initial *

What is your age? *

Pls select your sex : *

How do you hear about us? *

What is your email address? *

What is your phone number? *

I agree to By checking this box, you agree to allow us to contact you using the phone number provided. We may use this number to send you updates on our latest news, events, and other relevant information via text message or phone call.terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

What County/City and State do you reside in? *

What types of services are you interested in?

Individual Counseling

Couples Counseling

Family Counseling

Educational Classes

How do you plan to cover your sessions? *

What's is the name of your insurance provider?

What are your main objectives or areas you'd like to address through our services? *

What are your preferred times for appointments?

Is there any other general information you'd like to share with us?

By checking this box, I acknowledge that the information provided is accurate to the best of my knowledge. In addition, I consent to being contacted by Better Day Counseling for scheduling and further assessment. *

I acknowledge.

Captcha