Franchise Therapy Request Form

Therapy Request Form - Ellie Mental Health

Let’s find a therapist you vibe with! To get started, please complete this form to request a phone call where we’ll schedule your appointment. Sharing this info ahead of time will ensure you get matched more quickly with a therapist who really gets you (without spending unnecessary time on the phone).

Once your form is submitted, a member of our Ellie Client Access Team will call you within 1-2 business days.

By completing this form, you consent to have our team leave a voicemail and email offering more information. Caller ID and email address may show Ellie or Ellie Mental Health but no specific information regarding your request will be included within the voicemail or email.
In what State do you need services in?*
Choose an Alabama clinic/location*
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Choose a West Virginia clinic/location *
Choose a Wyoming clinic/location
Name*

First NameLast Name
Is the person seeking services a minor?

YesNo
Parent or Guardian Name if Minor
Please include your Full Name
Pronouns
Sex
Phone Number*

Area CodePhone Number
Email*
example@example.com
May we leave a voicemail message or send you an email if we are unable to connect with you by phone?

Yes, please leave a voicemailYes, please send me an emailYes, please leave a voicemail and send me an emailNo, please do not leave a voicemail or send me an email
Date of Birth*

MonthDayYear
Date
Are you following a provider who is moving to Ellie?*
If you are following a provider who is moving to Ellie, what is their name?*
Please provide a brief summary describing your goals in therapy or the type of support or services you are seeking:*

0/100
Would you like to use insurance?*
Do you want to fill in more information to save time on your follow-up phone call?*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company*
Group Number
ID Number
Payer ID
Often found on the back of insurance card!
Claims Address (often found on the back of insurance card)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is the policy holder for your insurance plan?

SelfRelative
Policy holder’s relationship to you
(ie. parent, spouse, etc.)
Policy holder’s name (first and last)
Policy holder’s date of birth
Policy holder’s address

Same as MineOther
Do you have a supplemental insurance plan?
Supplemental Insurance Company
Supplemental Insurance: Group Number
Supplemental Insurance: ID Number
Supplemental Payer ID
Often found on the back of insurance card!
Supplemental Claims Address (often found on the back of insurance card)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is the policy holder for your supplemental insurance plan?

SelfRelative
Supplemental Insurance Policy holder’s relationship to you
(ie. parent, spouse, etc.)
Supplemental insurance policy holder (First and Last name)
Supplemental insurance policy holder's DOB
Supplemental Policy Holder’s address
Please verify that you are human*
How did you hear about us?*

Internet Search (Google)Friend or Family MemberAnother Provider (ie. Doctor, case manager)An online advertisement (Facebook/YouTube)Psychology TodayOther Media (i.e. radio or TV)NewsletterAt a Community Event (ie. resource fair, presentation)Other
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Therapy Request Form - Ellie Mental Health