SOUTH TAMPA THERAPY~ Consult/ Triage/ Waitlist/ Discovery Call  
 
Hello,

Welcome to South Tampa Therapy & Mediation.

I, Elizabeth Mahaney, LMHC, MFT, LPC, CCTP, NCC, DCC, Ph.D, promise to triage as indicated, and refer you to trusted colleagues, if needed, on a case-by-case basis to the best possible referral and resources ~ as soon as possible.
 
I genuinely want to help!

*TIP: Finish filling out this form completely and Text me directly: 813-240-3237 to let me know.

If you would like to Self Pay for a virtual session with Dr. Elizabeth Mahaney, See availability and BOOK ONLINE HERE: www.SouthTampaCounselor.com/BookAppointment



Otherwise, please fill out this form and I will refer you to a colleague from our multidisciplinary team. 


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Email *
Phone #: *
Today's *DATE & *NAME *
*PRESENTING PROBLEM (What made you reach out today? What are your symptoms or Issues that you would like to work on?)
Appointment Type Needed: *
I prefer in-person sessions *
Required
I prefer virtual sessions *
Required
Are you Self Paying or do you have health Insurance that you would like to use?  Elizabeth Mahaney, LMHC, MFT, LPC, CTPP, NCC, DCC, Ph.D is only accepting SELF PAY at this time with a few exceptions.   Our team may accept United, Aetna, or Cigna and credentialed colleagues will be in touch based on your selections. Contact Administration: 813-240-3237 SouthTampaTherapy@gmail.com                        *
Required
INSURANCE: I understand that diagnostic criteria must be met and a diagnosis must be made from the Diagnostic and Statistical Manual of Mental Disorders (DSM5) to submit insurance. I understand pre-existing conditions due to a diagnosis. If you agree with this and would like an insurance quote, provide ALL of the following Information:

1. Your Diagnosis, 2. Insured I.D. Number, 3. Group Number, 4. Patient's First Name 5. Last Name 6. Date of Birth, and 7. Co-Pay$. (If applicable, EAP, Authorization Code). 

PROVIDE ALL INFO. (South Tampa Therapy utilizes Headway as a courtesy for billing insurance for clients) Please fill out ALL INFO  emailed to you from Headway to be eligible to use insurance for services).
Ideal Appointment Date & Time *
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Other Times and Days That May Work?
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Do you consent to state approved registered licensed colleagues/ interns, who collaborate with Dr. Elizabeth Mahaney at South Tampa Therapy, to reach out to you to facilitate the scheduling process to best meet your needs?                                                                                                 *
Any questions, concerns, or other information that would be helpful for me to know?
Thank you for reaching out! I am here to help. Call or Text 813-240-3237   Thanks,                                                                                                                                           Dr. Elizabeth Mahaney (Liz)
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