Register

Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Please send insurance info and drivers license/ID to faxpronto@yahoo.com or fax to 866-394-0482 for benefit check. Consent to Treat and Bill Insurance: I am hereby signing on behalf of myself and/or on behalf of my children to authorize mental health and/or counseling services to be provided by Counseling Centers International (CCI) and/or its counselor/therapists/clinicians. I authorize billing of my insurance for these services.

Client Information

/ Middle Initial

( optional )
 

( MM-DD-YYYY )






( for Text Message Reminders )

Bill To Contact

/ Middle Initial







Emergency Contact

First Name
Last Name
Phone
Mobile
Relation
Email
Street Address
City
State
ZIP Code

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )



Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )




( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )