Client Portal - TKR Counseling Services, PLLC

New Patient Request Form:

If you are a current or prior client with our clinic, please log in to the client portal OR contact our staff directly. If you are a new client, please complete the information below, and we will reach out to you shortly.

Personal Information:

First Name:*

Middle Name:

Last Name:*

Date of Birth:*

Gender of Legal Record:*

Male Female

Contact Information

E-mail:*

Phone:*

Address

Address type:		Street Address:

City:		State:

Zip code:

Legal Custodian

I am the client/patient seeking services.

I am a legal guardian, seeking services for someone under my care.

First Name:*

Last Name:*

Relationship:

Custodian Contact Information

E-mail:*

Phone:*

Custodian Address

Same address as client

Address type:		Street Address:

City:		State:

Zip code:

Provider:

Please explain the reason you are seeking help at this time.

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

Experiencing an emergency call 911 or go to nearest ER. Call Medina County Crisis Line 877-466-0660 Bexar County Crisis Line 210-223-7233

Insurance:

Insurance Company Name:

Member #:

EAP Information:

Employee Assistance Program Name:

EAP Authorization Code:

Phone Number:

Submit

Cancel

New Patient Request Form:

Personal Information

Contact Information

Phone

Address

Provider:

Please explain the reason you are seeking help at this time:

Insurance