New Client Appointment Request

Please correct the errors described below.

This form is not to be used for crisis situations. If you are in crisis, please use the following resources:

Crisis Line: 502 589-4313
911
Text HOME to 741741
Go to the nearest emergency room

Hi! Thanks for contacting me. This form asks for some basic information to help me learn more about your needs and make sure there's nothing that would get in the way of us working together. Once you've completed this form, I will contact you within two business days (usually sooner) to discuss our next steps. Please contact me at erin@vivariacounseling.com or 502 272-4950 if you have any questions.

First Name

Last Name

Pronouns (optional)

Email address

Would you like to receive an email reminder 48 hours before scheduled appointments?

Yes No

Phone number

Would you like to receive a text or phone call reminder 24 hours before scheduled appointments?

Text Phone call Neither

Insurance

Please note that if your insurance is not listed here, it is not one that I accept.

Are you 18 or older?

Yes No

If scheduling a telehealth session, will you be physically located in Kentucky at the time of the session?

Yes No N/A, I'm scheduling in-person

I would like to schedule:

A free 15-minute telephone consultation A free 15-minute video consultation A 50-minute initial video session A 50-minute initial in-person session

Your information will be encrypted.

This form is not to be used for crisis situations. If you are in crisis, please use the following resources:

Crisis Line: 502 589-4313
911
Text HOME to 741741
Go to the nearest emergency room

Erin Riedel, LCSW

Vivaria Couneling

502 272-4950

www.vivariacounseling.com
1169 Eastern Pwky Suite 3414, Louisville, KY, 40217

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