Appointment Request Form

If you have any questions about the information requested on this form, please contact admin@lotuscounselingservices.org.

Legal name of individual seeking services

Preferred name of individual seeking services

Date of Birth of individual seeking services

State of Residence

Email Address

Phone Number

Are voicemails okay?

Yes No

Are text messages okay?

Yes No

Name of partner/family member

Date of Birth of partner/family member

State of Residence of partner/family member

Email address of partner/family member

Phone Number of partner/family member

Are voicemails okay? (for partner/family member)

Yes No

Are text messages okay?

Yes No

Do you have an EAP authorization letter or email?

Yes No

Upload a picture of the EAP authorization letter or email.

Add file

Please upload a file

Please provide the following information: 1. Name of EAP provider. 2. Telephone number of EAP provider. 3. Authorization number that was provided to you when your sessions were authorized. 4. Number of sessions authorized. 5. Date range of authorization.

Even though you are using EAP, we request information about your insurance. This is because most people end up requesting to remain in services after their EAP sessions have been used. Checking your insurance benefits now will provide you with helpful information for continuity of care later. You will be under no obligation to remain in services or to use your insurance after your EAP sessions have been used.

What is the full name (first and last) of the primary insured?

What is the date of birth of the primary insured?

Upload a picture of the FRONT of your insurance card.

Add file

Please upload a file

Upload a picture of the BACK of your insurance card.

Add file

Please upload a file

Upload a picture of your driver's license or state issued ID.

Add file

Please upload a file

Upload a picture of your partner's or family member's license or state issued ID. Required for couples/family counseling appointment requests

Add file

Please upload a file

Your information will be encrypted.