Utah Infertility Resource Center · General Counseling Request

Name

*

First Name

Last Name

Email

*

Verify Email

*

Phone Number

*

I agree to receive occasional text messages from Infertility Connections (Not in regards to confidential information).

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Initial appointment preference:

*

Check all that apply.

Virtual

In person

No preference

Is there a specific therapist you would like to meet with?

We will do our best to schedule you with your requested therapist, but may not be able to depending on schedule availability.

Alison Brown LCSW

Cheri Fifield CSW

Marcus Hunt MFT (virtual only)

What time(s) are you available for therapy?

Check all that apply.

Morning (9 am to 12 pm)

Afternoon (12 pm to 5 pm)

Evening (5 pm to 8 pm)

Were you referred to us by a fertility clinic or other provider?

*

Including but not limited to acupuncturists, physical therapists, OBGYN, etc.

Please let us know which provider referred you:

*

How did you hear about us?

*

Facebook

Instagram

Google/Search Engine

Friend/Word of Mouth

News Article

Other

Other:

*

Do you have insurance you would like to use?

*

Yes

No

Name of insurance provider