Request a Brief Introductory Meeting

*The information in this form will be encrypted and transmitted securely and will only be accessed by a licensed mental health provider (psychologist, professional clinical counselor). This secure web form complies with the federal healthcare privacy law (HIPAA).

First name

Last name

Preferred Name

Email address

Phone number

If you will use your health insurance, would you like us to check your benefits and the cost of your counseling visits (e.g., copay, deductible, co-insurance)?

Yes

We'll ask you to provide your health insurance member ID number and date of birth. You'll have the option to upload a picture or pdf of your insurance card. We will gather information about your costs and discuss it with you in our brief introductory meeting.

Click "no" if you prefer to contact your health insurance to learn about your costs (deductible, copay, co-insurance)

What is your insurance member identification number?

Look for "Member ID" in the front of your health insurance card

What is your date of birth?

Please write the name of the month (e.g., 30 May 1991)

Add a picture or pdf of your insurance card here You can upload photos or a pdf of both sides of your health insurance card. If you encounter an error while trying to upload the photo or pdf, you can skip this step. You will be able to send a copy of your card later through the client portal

Add file

Please upload a file

Who would you like to work with?

Luis G. Cruz-Ortega, PhD; Licensed Psychologist

Accepting new clients

Vanessa Vargas, MS, MA; Licensed Professional Clinical Counselor

Not accepting new clients

Dr. Cruz-Ortega provides individual counseling for adults.
Ms. Vanessa Vargas provides individual and couples counseling for adults.

You may choose the method that is most convenient for you. However, if you are unwilling or unable to participate in telehealth visits at any time, we are not the best fit for you.

What state do you live in?

Dr. Cruz-Ortega provides telehealth services to residents in Ohio, Florida, and the states that participate in the Psychology Interjurisdictional Compact (PSYPACT). Click here for a map of participating states. Ms. Vanessa Vargas only offers telehealth services to Ohio residents.

When are you available? (Provide a few options: days and times)

Dr. Cruz-Ortega schedules appointments Mondays through Thursdays, from 12pm to 8pm (EST).

Ms. Vargas schedules appointments on Mondays & Tuesdays from 2pm to 7pm (EST), Wednesdays & Thursdays, from 10am to 6pm (EST), & Fridays, from 10am to 5pm (EST).

Briefly, what are you seeking help with?

Note: You may review our areas of specialty to help you figure out if we can assist you. If there is an opening that matches your schedule, you will receive an email with the day and time of your appointment or with instructions for scheduling your appointment through the online client portal.

I acknowledge that the brief introductory meeting is an informal conversation and it is not a clinical assessment or a counseling session. Nevertheless, what I discuss with the counselor will be confidential unless the counselor is concerned about my safety or someone else's. I understand that I can talk to the counselor if I have questions about this.

Your information will be encrypted.

Request a Brief Introductory Meeting

Luis G. Cruz-Ortega, PhD & Associates