Elevation Counseling Medication Management Appointment Request

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Elevation Counseling Medication Management Appointment Request - Telehealth

Please provide the information below and we will contact you about scheduling a Medication Management or Psychiatric Evaluation appointment. BE SURE TO HIT SUBMIT at the bottom of the form.

If you are filling this out for a child, please input the child's information not your own.

Please add office@elevationcounseling.com to your contacts, or check your spam folder often, as our appointment emails can sometimes get screened out!

Are you currently an Elevation Counseling client or will you be a new client to Elevation Counseling? *

Existing Elevation Client

New Client

Other:

Client's First Name *

Client's Last Name *

Client's Date of Birth *

Cell Phone Number *

Email Address (we will contact you by email - only list an email to which you agree to receive scheduling communication. By agreeing to email communication you acknowledge and accept the inherent privacy risk of email communication) *

What is the general nature of your reason for seeking Medication Management or Psychiatric Care? At this time we DO NOT have providers who treat adult ADHD. *

Health Insurance Member ID or Medicaid # *

What health insurance do you have (if any) (BCBS Centennial Care, BCBS PPO / HMO, Presbyterian Centennial Care, Presbyterian PPO, United Health, UMR, Western Sky, Molina, Tricare, Medicaid, Etc. )? We do NOT take Medicare, Cigna, or Aetna. *

Let us know if you have certain days or times you need to schedule your appointments. If you are flexible (great!) please check the "I'm Flexible" option. *

I'm flexible!

Other:

Required

How may we contact you for scheduling? (check all methods that you are willing to receive). *

Phone call

Text

Required

Please confirm each of the following policies of Elevation Counseling *

I am aware of the 24-hour cancellation policy ($55 late cancels or no-shows)

I am not seeking court-ordered therapy or therapy for child custody arrangement or divorce proceedings

I am not seeking assessment for disability or SSA benefits (we can provide suggested referrals)

Required

Are you currently experiencing suicidal thoughts? If so please call 911 or the New Mexico Crisis And Access Line as soon as possible. They are available anytime 24/7/365 1-855-NMCRISIS (662-7474). This form simply adds you to a waitlist and it may be some time before we are able to contact you. *

Yes

Have you recently been released from in-patient care or hospitalization? *

Yes

Other:

BE SURE TO HIT SUBMIT! Thank you for sending this information. We will get back to you shortly about scheduling your first appointment.

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