Counseling Within Reach, PLLC Appointment Request Form

Counseling Within Reach, PLLC Appointment Request Form
Disclaimer: Emergency assistance and Crisis Support are not available through this form. If this is an emergency, please call 911 or go to the nearest ER. For 24/7 non-emergent crisis support, call or text the National Suicide Prevention Lifeline at 988.
Therapist's Summer Availability: By scheduled appointment only. Generally, Monday-Thursday, 9am-3pm, with some variations to this. Occassional Friday availability.
Please list your preferences for appointments. Days of the week and timesframes.
Requested Services:

Free, 15 minute ConsultTelehealth Intake / Counseling
Any preference for the initial contact method(s) from this web form (phone, email, text)?
Consent to contact:

Phone call, may leave voicemail with counselor's name / practice information and callback numberPhone call, leave generic voicemail only (Provider's name (not title) and callback numberText (If text is preferred, a hipaa secure link for texting can be sent through Spruce Health.Email (To send hipaa secure client portal invitation, telehealth session link, and appointment notifications / reminders)
Legal Name

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com
Insurance Provider (if applicable)
Policy Holder

First NameLast Name
Insurance ID #
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Desired topics / goals to address in counseling:
The therapist will review this web form and reach out to you, typically within 1-2 business days.
Should be Empty: