Appointment Request Form

AMRI Counseling Services Appointment Request Form

Once the form is completed, we will contact you within 1-3 business days to schedule an appointment.
Date

MonthDayYear
Date
Full Name of Client*

First NameLast Name
Client Phone Number*

Area CodePhone Number
Client Date of Birth*
Client Social Security Number*
Gender*
Ethnicity*
Referred by:*
Client E-mail*
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent or Guardian Name

First NameLast Name
Parent or Guardian Phone Number

Area CodePhone Number
Parent or Guardian Email Address
example@example.com
Parent or Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Emergency Contact Email
example@example.com
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List your Insurance company*
Insurance Card ID*
Group number if applicable
Type no Insurance here if you are "SELF Pay"
Upload Front of Insurance Card*

Browse Files

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Upload Back of Insurance Card*

Browse Files

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Upload Copy of your ID, Drivers License or Passport*

Browse Files

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Upload Medication List

Browse Files

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Upload any another document you would like to share

Browse Files

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Reason being seen? List services are you interested in?*

DepressionAnxietyStressPost Traumatic Stress/ TraumaGrief/ LossAnger ManagementDomestic ViolenceAlcohol or Drug Use (AODA)Marriage/ Couples CounselingFamily CounselingOther
What days work best for you?*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What time works best for you?

MorningAfternoonEvening
Requested service: Please List In-person or Virtual (Telehealth via phone or Video)*
Preference: Please list Male, Female, or No preference*
I would like to receive our newsletter and other helpful information/resources that we provide to clients?*

YesNo
** To expidite the process please click the link below:

https://www.therapyportal.com/p/amricounseling4001/
Should be Empty:

AMRI Counseling Services Appointment Request Form