Appointment Request Page

Name

Date of Birth

Email

Phone

Insurance (please specify it is a commercial or Medicaid/Centennial plan)

Preferred Counselor

Counseling Only

Medication Management Only

Medication Management and Counseling

Spanish-Speaking Therapist

LGBTQ+ Experienced Therapist

Are you a First Responder?

Option 1

AFR

Option 2

Bernalillo County Fire Dept

Option 3

Other First Responder

Please choose by clicking on a box to let us know, if you prefer Telehealth, In Person or Either

Option 1

In Person

Option 2

Telehealth

Option 3

No Preference/Either Will Work

Please give general idea of what is brining you in for counseling (used for matching with a therapist) and add any additional information needed