Intake Request Form
Thank you for your interest in establishing care with Reflect Psychological Services! Please take 5-10 minutes to complete the form below in order for Dr. Ariel learn a bit about you.

Please note: this form should not be used in emergencies. If you are experiencing a medical or psychiatric emergency, please call 911 or visit your nearest emergency room.
Anwani ya barua pepe *
Name (First and Last) *
Please indicate the name that you would like to be addressed by, if different from your legal name, including your pronouns so that Dr. Ariel may refer to you correctly.

For example: Barb she/her (as opposed to Barbara she/her)
Address (Permanent Residence) *
Phone number *
Age *
Gender Identity
Racial Identity
How did you hear about Dr. Ariel/Reflect Psychological Services? *
If you responded "Other Therapist/Healthcare Provider" above, please indicate the name of the provider below:
Are you physically located in the State of Illinois? If not, please list your permanent state of residence. 

Please note: Dr. Ariel is authorized to provide virtual/telehealth clinical services to clients/couples who reside in PSYPACT states. Check to see if your state participates in PSYPACT here: https://psypact.org/mpage/psypactmap 
 *
What about Dr. Ariel's website/profile led you to reach out to her specifically? *
In about 3-5 sentences: what brings you to therapy at this time (difficulty coping with stress, childhood trauma, racial/identity-based trauma, relationship conflict, time management difficulties, attention/concentration challenges, career stress/burnout, etc.)? Is there anything specific, such as a particular event?  *

What do you hope will be different in your life as a result of beginning therapy (career, health, relationships, family, self-worth etc.)? Do you have any particular goals for therapy? (No worries if you are not quite sure yet!)

 *
Have you participated in therapy before? If so, does anything stand out to you as helpful and/or unhelpful? *
Please check all of the boxes that apply to you currently: *
Lazima ijazwe
Please note prior to proceeding: Dr. Ariel is currently an out of network provider for all insurance companies. This means that you would pay for your care with Dr. Ariel out of pocket. Payment is due at the time of service. Upon request, Dr. Ariel can provide you with a superbill for your sessions that you may use to seek reimbursement directly from your insurance company. Each insurance company determines client coverage/reimbursement rates for out of network providers. Reimbursement can range from 0-100% and is not guaranteed. If you are interested in seeking reimbursement, please contact the phone number on the back of your insurance card to inquire about your out of network mental health provider benefits.

Additionally, some clients prefer not to utilize their insurance at all and self-pay due to personal desire to maintain the complete privacy of their treatment records and diagnoses. If you choose to opt-out of insurance coverage and obtain care with Dr. Ariel without seeking reimbursement from your insurance, Dr. Ariel will provide you with a Good Faith Estimate of your services for your financial planning purposes.

Please select one of the choices below:
Futa uteuzi

Dr. Ariel's current fee structure is as follows:

Individual clients will initially meet with Dr. Ariel for an Individual Initial Assessment (60 minutes). Follow up sessions are billed according to session length indicated in the table below (typically 45 or 60 min sessions).

Couples will first meet with Dr. Ariel for a Couples Initial Assessment (90 minutes). Follow up sessions are billed according to session length indicated in the table below (typically 45 or 60 min sessions).

Please select which service(s) you are interested in:

Picha isiyo na manukuu
Scheduling & Availability
Appointments are currently held virtually Monday-Thursday from 8:00 AM - 6:00 PM CST and Friday 9:00 AM - 12:00 PM CST. Afternoon appointment times tend to reserve quickly, so please check all possible times that you would be available on a weekly/consistent basis. 

Please note: if Dr. Ariel does not have availability that matches your scheduling needs (within a reasonable timeframe) or if she does not believe that she is the best fit for you at this time, Dr. Ariel will make an effort to provide contact information for referrals.

Weekly availability - Please select all possible Central Standard Time (CST) time slots you could schedule a weekly appointment:

Please note: this is not an accurate representation of current open time slots.
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
8:00 AM (CST)
9:00 AM (CST)
10:00 AM (CST)
11:00 AM (CST)
12:00 PM (CST)
1:00 PM (CST)
2:00 PM (CST)
3:00 PM (CST)
4:00 PM (CST)
5:00 PM (CST)
Do you have a private/confidential space to engage in teletherapy? *
Is there any particular week/date that you are hoping to begin services? If you have a strong preference for a certain hour/time listed above, please note this here.
 *
Is there anything else that you would like Dr. Ariel to know that would be helpful for your work together?
Thank you for taking time to complete the Intake Request Form with Reflect Psychological Services. We will respond to your inquiry within the next 1-2 business days. We look forward to connecting with you! 

By submitting this form you acknowledge and accept that risks of communicating your health information via this unencrypted means and wish to continue despite those risks. By clicking "Yes" you agree to hold Reflect Psychological Services harmless for unauthorized use, disclosure, or access of your health information sent via this electronic means.

I agree to the Terms and Conditions.

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Lazima ijazwe
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