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).

Shanique is Full - Do not self-register for Shanique
You may self-register online and complete all the initial paperwork. Once we receive your initial registration, keep an eye out for either a phone call or email from our Clinical Admin Coordinator, reaching out to you to schedule your first appointment. You should expect to hear us within 24-48 hours. If you contact us over the weekend, we will respond sometime on Monday. Thank you and Welcome! Guillaume Marriage and Family Counseling

Therapist

Client Type

Client Information

/ Middle Initial

( optional )
 

( MM-DD-YYYY )


( optional )
( optional )






(optional) (required)
( 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. )