Appointment Request Form

Please Match Me to a Counselor

Complete the following information to request an appointment. If you are an existing client or are a new client and you have a specific counselor you wish to see, please refer to the counselor list and request an appointment with that particular counselor. We will take the information you have provided and work with you to find a counselor that will be most suitable for you.

Please note that the practice is sometimes at full capacity and may have a waiting list. If this is the case, you will be offered a referral to another provider.

Your First and Last Name


Client's First and Last Name


Email Address (if okay to contact by email)


Primary Phone


Secondary Phone


Your Availability or Preferred Meeting Times and Dates

Comments or Description of Issue


Insurance / EAP Information:

The practice will obtain the benefit information, any required pre-authorization, and link you to a counselor who is in-network with your plan using the information below. Please call with the following details if you do not wish to transmit this information electronically. If you are using an EAP, please specify in the comments above and include the authorization number you were given by your EAP vendor (if applicable). Thank you.

Insurance or EAP Company (if self-paying, please note and disregard remaining fields)


Insurance or EAP Phone Number


Member / Subscriber ID


Group Number


Policy Holder Name


Policy Holder Date of Birth


Policy Holder Address



Client Date of Birth (if client is not policy holder)


Client Address (if client is not policy holder)