Contact Name * First Name Last Name Phone * (###) ### #### Date of Birth * MM DD YYYY Email * What Services Are You Interested * Individual Counseling Marriage & Couples Therapy Marriage and Couples Intensive Group Counseling Family Counseling Child Counseling The Mind Spa How'd You Hear About Us? * Referral Facebook Instagram Google Therapy for Black Girls Psychology Today Other Your Availability * Morning (9AM-12PM) Early Afternoon (12PM-3PM) Late Afternoon (3PM-6PM) Payment Method * Insurance Self-Pay How soon would you like to start? * Immediately! As soon as you have an opening, In the next few weeks In the next few months Not sure! Just exploring my options Primary Health Insurance Carrier Note: JCC only accepts United Health Care, Blue Cross Blue Shield, Health Choice, Aetna, and Cigna. Any of other providers would have to be self-pay. Name of Policy Holder (If paying by insurance) First Name Last Name ID Number What should we know before we connect? Thank you! Phone 918- 221 - 8382Emailinfo@joychristiancounseling.comAddressJoy Christian Counseling6316 E. 102 St, Ste 102Tulsa, OK 74137
