Appointment Request Form

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

Legal name

Preferred name

Unfortunately, Monica does not have availability to accept new clients. However, she personally supervises the other exceptional clinicians listed on this form. By choosing to work with one of these clinicians, Monica will be working “behind the scenes” to support you on your journey. You can review bios of other clinicians within the practice by using this link: Meet Our Clinicians.

Date of Birth

State of Residence

Email Address

Phone Number

Are voicemails okay?

Yes No

Are text messages okay?

Yes No

Please briefly describe what you want to target in therapy.

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? (for partner/family member)

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 insurance card for EACH insurance plan you have.

Add file

Please upload a file

Upload a picture of the BACK of your insurance card for EACH insurance plan you have.

Add file

Please upload a file

Upload a picture of your driver's license or state issued ID. For minors, BOTH parents/legal guardian's licenses or state issued IDs are required. You can upload multiple files.

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

IMPORTANT Insurance Notice: It is extremely important for Lotus Counseling Services, PLLC to know of each insurance policy that you may have, even if we do not accept that particular insurance or you do not want to use that insurance. This is because when you have multiple policies they are designated primary, secondary, tertiary, etc. This designation determines which policies we have to bill and in which order we bill them. We cannot bill all of the policies at the same time. You are not able to select which policy we bill first, second, and so on. The insurance company will determine in what order the policies have to be billed. If we do not have all of the necessary information to bill your insurance provider(s) correctly, claim processing errors can occur that can lead to you being responsible for hundreds or thousands of dollars, sometimes years after services have been received.

I have listed all insurance policies that I have on this form. I am paying out of pocket for services. I have NOT listed all insurance policies that I have.

What is the name of the person and their profession that referred you?

Please explain how you heard about us.

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