Scheduling Form

Name

First Name

Last Name

Partner's name

First Name

Last Name

Reason(s) for seeking therapy

Scheduling preferences

I will do my best to accommodate any scheduling requests. I see clients M-Th 10am-7pm.

Therapy Type

Please check below

I confirm that I reside in Minnesota and will be in Minnesota for all therapy sessions

I understand that all consultation and therapy sessions with Clover Counseling will be conducted via telehealth