YMCA of the North Employee Appointment Request Form

Ellie Mental Health has partnered with YMCA of the North to provide up to 4 sessions per employee with our team of mental health therapists!
This service is funded by the employer and is meant to encourage employees to do more for themselves & feel supported in doing so.
While the YMCA will cover the cost of 4 sessions with one of our therapists, all client records will be kept totally confidential.
While not everyone is ready for or seeking traditional therapy, there are many who are “just wanting to check in with someone”, starting with a personalized wellness consultation before fully diving in. Others may have been thinking about therapy, or have tried it in the past, and are ready to start with therapy right away.
You are in the driver’s seat! Let our client access team know what type of support you’re looking for and any life stressors you want to navigate, and they will match you with a therapist who will support you on your wellness journey.
Because these sessions are not billed to insurance, a thorough diagnostic assessment will not be required unless you choose to continue services at Ellie after your employer-sponsor sessions have been utilized.
These appointments have the option of being held virtually with one of the therapists via Microsoft Teams, or in person at one of our 24 MN clinic locations.
If you utilize all 4 sessions and would like to continue to see a therapist at Ellie, you will be able to utilize your insurance (Ellie accepts all major insurance plans, including state-funded plans!) or choose to pay out of pocket.
To get scheduled, please complete the following request form or call 651-313-8080. If we have availability during one of the times you listed, you will receive a phone call to get more information and/or schedule your appointment.
Once scheduled, you will be sent a brief intake packet which will be required for you to fill out prior to your first session.

Name*

First NameLast Name

Date of Birth*

Date

Legal Sex*

Preferred Pronouns *

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Please list 3-4 dates & times within the next week that you are available for a 50-60 minute Wellness Consultation or therapy session. Please note: availability is typically limited to regular business hours (Mon-Fri 8am-5pm). *

**Your Wellness Consultation will be scheduled within one of these time frames & confirmation will be emailed to you. If there are no available appointments during the above dates & times, you will receive a phone call from Ellie Mental Health staff to find another time that works for you.

Please indicate whether you want to schedule a Wellness Consultation or a therapy session:*

Wellness ConsultationTherapy SessionNot Sure (someone will reach out to you to help you make the decision!)

Please indicate topics of interest for your Wellness Consultation or therapy session*

Select Preference for In-Office Location or Virtual Appointment

Insurance Company

Group Number

ID Number

Who Is the Policy Holder for This Insurance Plan?

ClientRelative

Please Upload Photos of the Front and Back of this Client's Insurance Card.

Does This Client Have a Supplemental Insurance Plan?

Type option 1Type option 2Type option 3Type option 4

I understand that I will be given up to 4 50-60 minute Wellness Consultations and/or therapy sessions from a practitioner at Ellie Mental Health as part of a wellness initiative offered by my employer.*

I understand that my employer will not be notified that I (by name) have attended the Wellness Consultation/therapy session, and that the only information that will be provided to my employer is the number of employees who attend.*

I understand that my employer will NOT be notified about any personal information shared during the Wellness Consultation/therapy session.*

I understand that I will not be engaging in medically necessary or other therapeutic services and no part of the Wellness Consultation/therapy session will be considered treatment of any medical or mental health disorder. *

I understand that if I decide that I might benefit from ongoing services (at my own cost, not paid for by my employer), Ellie Mental Health will help me identify what those services might be and make referrals for further support at my request.*

I will not hold Ellie Mental Health liable for any outcomes that may result from engaging in a Wellness Consultation/therapy session, and if I have any questions regarding my Wellness Consultation/therapy session, I will talk to a member of the Ellie Mental Health team. *

I understand that, if i pursue therapy sessions at Ellie Mental Health, additional forms and intake paperwork will be required for me to fill out.*

I understand that the only documentation of the Wellness Consultation/therapy session will be this consent form (and any additional consent forms/intake paperwork required by Ellie Mental Health) and will be stored in a protected file at Ellie Mental Health, with access limited to the administrative & executive teams.*

By signing this form below, I agree that I understand the preceding information outlined regarding engaging in a Wellness Consultation at Ellie Mental Health. *

Date*

Date

YMCA of the North Employee Appointment Request Form

Before engaging in a Wellness Consultation or therapy session at Ellie Mental Health, please review and initial that you understand the following information.