Service Inquiry Form- Dormetra Henry, LPC

Confidential Inquiry Form
Dormetra Henry, LPC

Please fill out the confidential form below. Dormetra Henry will contact you on the next business day to answer any questions you may have and potentially set up your first visit.
If you want to connect more quickly please call 832-548-9625

Client First Name

Client Last Name

Please indicate your interest with Dormetra Henry, LPC.

Cell Phone Number

Would you like to receive relational and mental health resources from Fuller LIfe?

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How did you find out about Dormetra Henry, LPC?

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If other selected, please specify.

Please share anything else you want Dormetra Henry to know:

Would you like to find out if your insurance would cover the cost of therapy?

(Optional) Insurance Details

Subscriber Name

Subscriber Date of Birth

Relationship to Subscriber

Name of insured

Insurance company

Policy number

Group number

Claims address

Customer service or benefit phone number

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