Kelly Counseling and Associates, LLC

1801 North Wood Avenue, Florence, AL 35630

New Client Information

Interested in working with one of our counselors?

Please complete the following form and you will be contacted within two business days to review information and discuss scheduling options. 

If submitting this form via our mobile site, please ensure the entire form is complete and you select submit. If you do not see the entire form, select Desktop View.

If you don't have computer access, or if you prefer, contact us at 256-766-9804 Extension 6

Verification of Eligibility/Benefits

If you are interested in using Insurance Benefits or Employee Assistant Benefits to pay for counseling services, please complete the following information. You may upload a copy of your insurance card to attach to this form.

By completing and submitting this information you are giving permission for the clinical and/or administrative staff of Kelly Counseling & Associates to view your benefits. Verification of benefits is not guarantee of payment.

Prefered Contact Method
Insurance Company
Employee Assistance Plan
Reason/s For Seeking Support (this remains confidential)
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