New Patient Intake Form
Welcome to Alliance Counseling Works. In order to speed up your onboarding and scheduling process, please take a few minutes to complete this new patient form. After we receive this form, our office will review options for an appointment with your preferred therapist if you selected one. Please allow up to one full business day for a response. Thank you for choosing Alliance Counseling Works.
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Clients First Name *
Clients Last Name *
Preferred Phone Number *
Please enter the phone number you prefer to use appointment reminders and notifications.  (For MINORS, use parent/guardian)
Contact Email *
Please enter the email you prefer to use for your new patient portal, appointment reminders, and notifications. (For MINORS, use parent/guardian)
Please give Clients date of birth. *
MM
/
DD
/
YYYY
Primary Contact (Parent/Guardian) First, Last Name * If client is a MINOR*
Type of Therapy *
Choose Your Location *
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Why are you looking for a therapist at this time?
Just a brief sentence or two. Please do not disclose details or sensitive information.
 *
How would you like to be contacted for scheduling options? *
Consent to Submit Information Digitally
Alliance Counseling Works is HIPPA compliant and will not share any sensitive information or data with third-parties or non-HIPPA compliant systems. By agreeing to submit your information electronically, you agree that we can communicate with you via email regarding appointments but also opt-in to receive ACW news and helpful information. If you prefer not to submit your information electronically at this time, please call our office to set-up your appointment. Our number is 512-763-2186.
Do you accept? *
If you are in a crisis and require emergency assistance, do not wait for the clinic to reply to your message. Please call 988 or go to the nearest emergency room. People in need of mental health support in Texas and across the United States can now call or text 988 for the National Suicide Prevention Lifeline.
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