CRS New Client Request

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Welcome to CRS! Please complete the request form below. We will contact you to discuss therapist options and appointment availability as soon as possible. **NOTE: We are currently experiencing an unprecedented volume of referrals, so there may be a delay in our ability to reach out as quickly as we are typically able to, but we WILL reach out!** Please only complete the form once. Your patience is much appreciated!

***Please be aware of the following***

If you are a parent seeking help for your child, please input YOUR information first, and answer questions concerning your child in Section 3.
For all clients reaching out: completing this form does not guarantee an appointment.
All information submitted is private and confidential.

Click here for information about insurance options and self-pay rates.

We offer both in-person and virtual sessions (dependent on therapist).
*Please contact your insurance carrier to see if telehealth is a current covered benefit under your plan.

First Name *

Last Name *

Pronouns

Date of Birth *

YYYY

Phone Number *

Email Address *

Preferred Communication (Please select email for the quickest response!) *

***NOTE*** We are currently able to respond via email or text.

E-mail

Text

Phone Call

What is your preferred language? *

English

Spanish -- Solicite una cita: https://docs.google.com/forms/d/e/1FAIpQLSegvKI3RwHChj_JAZyQPfK-t6hyv9C2Gu2JICmHl1LS2qmH6g/viewform

American Sign Language

How did you hear about us? *

I'm a previous client

I'm a current client

I have a friend or family member who is a current client

Someone told me about CRS who is NOT a current client themselves

I know a CRS therapist personally

Psychology Today

Insurance Provider List (Cigna, Aetna, Anthem BCBS, Beacon)

Colorado Medicaid Provider List

Employee Assistance Program

Google/Internet Search

Social Media (Facebook; Instagram)

Referring Agency or Another Provider (Please specify source under "Other")

Other:

Required

Do you personally know any of our therapists, and/or is a member of your family/friend group currently seeing a CRS therapist? (If yes, please provide their name) *

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