Contact Us Established clients may click here to log into our client portal. Name(Required) First Last Email(Required) Enter Email Confirm Email PhoneDate of Birth MM slash DD slash YYYY Primary ConcernPlease let us know how we can help.How did you hear about New Salem Counseling? Church/Pastor Family/Friend Online Search Social Media Drive by Other If you are seeking counseling, please provide the following information: Individual Couple Family If you have a specific counselor you would like to see, please list below. If not, we will offer some suggestions.Do you have a preferred gender of counselor? No Preference Male Female captchaConsent(Required)By submitting this form via this web portal, you acknowledge and accept the risks of communicating any health information via this unencrypted email and electronic messaging, and you wish to continue despite those risks. By clicking "Yes, I agree to the privacy policy" you agree to hold New Salem Counseling harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means. I agree to the privacy policy.EmailThis field is for validation purposes and should be left unchanged.
