Request an Appointment - GlassWing Counseling

Complete the information requested below and submit. We will contact you as soon as we can to set up an appointment.

First Name(required)

Last Name(required)

If a minor- Parents name

Email (required)

Date of Birth(required)

Phone Number(required)

Address(required)

Apt/Suite

City(required)

Zip/Postal Code(required)

County (Shurburne, Isanti etc.)(required)

Insurance Company (BCBS, Medica etc)(required)

Insurance ID number(required)

Do you have secondary insurance?(required)

If yes, what is the insurance company and ID Number

Reason you are seeking counseling(required)

Individual or Couples?(required)

Are you looking for online or in person sessions?(required)

What is your availability? (We are open Monday-Thursday 10am-6pm)(required)

How did you hear about GlassWing Counseling?(required)

Anything else you would like us to know?