UCA Appointment Request

If you have an emergency, dial 911. If you are having a mental health crisis, call 800-273-8255. All prospective new patients, and referrals, please complete the below form. If we are unable to schedule you with one of our counselors, you will be provided a list of trusted providers we work with, that accept your insurance/payment needs. We will be in contact via email as soon as we are able to process your request.

Please correct the errors described below.

If a counselor's name does not appear in the drop-down menu, they do not currently have availability.

Please include any past diagnoses here.
If you have a specific therapy method (EMDR, etc.) you are interested in, please indicate it here.

Any information included on this form, is sent to us via a HIPAA-compliant encryption software, and treated with the utmost confidentiality.

Your information will be encrypted.

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