Franchise Therapy Request Form

Therapy Request Form - Ellie Mental Health
To request an appointment, please complete the following form. A member of the Ellie Client Access team will be in touch within 1-3 business days.
In what State do you need services in?*
Choose an Arizona clinic/location*
Choose a Colorado clinic/location*
Choose a Connecticut clinic/location*
Choose a Florida clinic/location*
Choose a Georgia clinic/location*
Choose an Idaho clinic/location*
Choose an Illinois clinic/location*
Choose an Indiana clinic/location*
Choose a Maryland clinic/location*
Choose a Michigan clinic/location *
Choose a Mississippi clinic/location*
Choose a Missouri clinic/location*
Choose a New Jersey clinic/location*
Choose a North Carolina clinic/location*
Choose an Ohio clinic/location*
Choose an Oklahoma clinic/location*
Choose a Pennsylvania clinic/location*
Choose an South Carolina clinic/location*
Choose a Tennessee clinic/location *
Choose a Texas clinic/location *
Choose a Utah clinic/location *
Choose a Virginia 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
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 Mine
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)Other Media (i.e. radio or TV)NewsletterAt a Community Event (ie. resource fair, presentation)
Should be Empty:

Therapy Request Form - Ellie Mental Health