Mental Health Appointment Request Form
Fill out the form below and one of our therapists will be in touch. *PLEASE NOTE* if you are experiencing a mental health emergency, call the Mobile Crisis Outreach Team (MCOT) 1-800-273-8255, or 911
Name
*
First Name
Last Name
Gender
*
Male
Female
Trans
Non Binary
Gender Queer
Something else
Phone Number
*
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
E-mail Address
*
example@example.com
Please provide the name of your insurance provider, or indicate that you plan to self-pay.
*
Self-Pay
Insurance - List insurance provider below
Have you accessed services at UAF before?
*
Yes
No
Please briefly tell us why you are looking for counseling services at this time. *These answers are confidential.
*
How were you referred to mental health services at UAF?
Please Select
Psychology Today Profile
Google/Search Engine
LGBTQ Therapist's Guild
UAF Medical Provider
Other Medical Provider
Other
Thank you for reaching out!
Our therapists will contact you via email within 72 hours.
Submit
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