Request an Appointment

Emergency Assistance

If this is an emergency, call:

Crisis Text Line: 741741
Emergency Line: 911
Suicide Hot Line: 988

Client Information

About Your Appointment

First name

Last name

Gender

Client Date of Birth

Home Address

Apt #

City

State

Zip Code

I agree to receive text communication from you. Msg & data rates may apply. Messaging frequency varies. Text STOP at any time to opt out of receiving SMS text messages or HELP for assistance.

Phone Number (Provide if you have agreed to receive electronic communication through this format.)

I agree to receive email communication. I understand that I may opt out of receiving email communication at any time by contacting the office by email or phone.

Email address

Insurance Information

Insurance Provider Phone Number

Insurance Member ID

Insurance Group Number

Billing Address

Your address on file with the insurance company.

Apt #

City

State

Zip Code

Primary Insured Information

Are you the subscriber for the insurance policy? If you are not the primary prescriber for the insurance policy, the Primary Insured information is needed for insurance purposes.

Yes

If yes, please go the next section.

If no, please provide the Primary Insured Information. This information is required.

Primary Insured First Name

Primary Insured Last Name

Primary Insured Date of Birth

Primary Insured Gender

Primary Insured Phone Number

Primary Insured Relationship to Client

Primary Insured Billing Address

Address, City, State, Zip Code on file with insurance company.

Secondary or Supplemental Insurance-IF APPLICABLE

Please provide if you have more than one insurance for medical which covers mental health services. Medicare members may have supplemental insurance.

Member Number for Secondary or Supplemental Insurance-IF APPLICABLE

EAP Information - If using EAP, please complete in entirety.

Employee Assistance Program Insurance Company

EAP Pre-Authorization Number

For EAP appointment request only

EAP Validation Dates

Start and End dates needed

Number of EAP Sessions Authorized

needed for EAP authorizations

If you are planning to request documents for FMLA, Short/Long Term Disability, Accommodations, etc., please provide information below.

I do not provide animal support letters.

Availability for Sessions

Morning 9:00 am to 12:00 pm

Afternoon 1:00 pm to 5:00 pm

Evening 5:00 pm

Note that the 5:00 pm time is usually booked, but it can be requested.

Best Contact Method

If you have agreed to receive emails.

Text

If you have agreed to accept texts.

Call

Please explain your specific needs for you visit below.

Please note that I do not provide couples counseling services.

Information Needed to Provide Services

Please check this box to confirm that you are 18 or older or are requesting services for someone over the age of 18.

Please check this box to confirm that you are a Texas resident.

Please check this box to confirm that you are an Indiana resident.

Your information will be encrypted.