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Therapy Appointment Request Form
Please fill out the following questions and we will reach out to you within 24 hours
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* Indicates required question
Name
*
Your answer
Email Address
*
Your answer
Phone
*
Your answer
I am seeking counseling for:
*
Myself (individual counseling)
A friend or family member
Required
Briefly describe what you are hoping to work on in therapy:
*
Your answer
My insurance
*
Blue Cross Blue Shield
Aetna
Medicare
United Healthcare
Other
Days I could schedule sessions
*
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Weekends
Required
Ideal Appointment Times
*
Early mornings (7-9am)
Late mornings (10-12pm)
Early Afternoons (12-2pm)
Late Afternoons (3-5pm)
Evenings (after 5)
Required
Times I COULD make work if needed
Early mornings (7-9am)
Late mornings (10-12pm)
Early Afternoons (12-2pm)
Late Afternoons (3-5pm)
Evenings (after 5)
Please check any therapy structure you are open to:
*
Virtual teletherapy using a HIPAA compliant video and virtual whiteboard
Phone
Required
How did you hear about us?
*
Psychology Today website
Google search
Therapy Den website
Mental Health Match website
Found on insurance in-network provider list
Referral from current or past client
Referral from a medical professional
Referral from Student Health Center
GoodTherapy website
Other:
If other, please specify:
Your answer
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