DePaul Counseling New Referral Information Form

Patient Name and Date of Birth

Please note that I am only offering Virtual sessions, by Video or Telephone

Person Completing Form (if other than patient). What is your relationship to the patient? If the potential patient is 18 years of age or older, he or she will need to contact me directly. Thank you.

You may only complete this form for yourself or for your child / dependent, 17 years old, or younger.

How did you hear about me?

Referred by current or previous patient Referred by my Insurance or EAP Internet search Psychology Today Other

What is the primary reason you are seeking counseling? You may be brief (marriage, stress, etc)

If you would like to provide a more detailed explanation of why you are seeking counseling, you may do so here, but it is not required.

How will you be paying for your counseling?

I will be self-paying and not using Insurance or EAP benefits. My Insurance, Dr. DePaul is a Network Provider. I have an EAP authorization number specifically to see Jeff DePaul, Ph.D., LMHC

What is the name of your Insurance Company or EAP Company?

Aetna United Health or United Behavioral Health Optum Beacon Health Options Anthem (only EAP cases, not Anthem Insurance) Advent or Health First Aetna Tier 2 Only

How soon do you need to be seen?

2-3 Business Days 5-7 Business Days Within two weeks

What are your preferred appointment days and times?

I'm generally available Monday - Wednesday 9:00 am to 5:00 pm

Please provide the email address where you would like to receive my response.

In the event that I can not respond by email, please provide a phone number where you would like to be reached.

I am exclusively offering Telehealth services.

Telehealth works well for me.

Your information will be encrypted.