Counseling Appointment Request Form

  • Counseling Appointment Request Form

    Isabel Vee Counseling

  • Please fill out the form below to request an appointment.

  •  -
  • Date of Birth*
     - -

  • Requested Services

    You can select more than one service.

  • **Please note we primarily provide Individual Counseling for Adults (18 yo+). However, we may be able to accomodate ages 14+

  • What Type of Service are you seeking?*

  • How do you plan on paying for services?

  • If using EAP Benefits, please indicate which company (SKIP if not using EAP):

  • Insurance Information

  • To expedite scheduling, please provide the following information.

     

    If you have medical insurance, it is important that you provide the information below. By doing this, the referral process is moved along more quickly.

    **You agree that by providing your insurance information, you are granting Isabel Vee Counseling the right to verify your insurance information in order to determine your coverage, co-pays, and/or deductibles.

  • Who is the Primary Policy Holder (person insurance is under)?*

  • Insurance Provider (If applicable).*

    • If you cannot provide at this time, or don't have your insurance information available, please enter NA

  • If you are NOT the primary policy holder, please enter the primary insured's information below:

  • Primary Insured's Date of Birth
     - -
  • Upload Files
    Cancelof

  • Pre-screening

  • Sessions

  • Would you prefer a free 15-minute phone consultation before scheduling a counseling appointment? Please indicate below.

    **Please note that requesting a consultation may delay the start of your counseling sessions due to scheduling demands. Additionally, a free consultation is not guaranteed. Knowing your preference will help us understand your needs better.

  • Phone Consultation Preference

  • Once sessions begin, what is your preferred format?*

  • Specific Day and Time (if applicable):

    If you have a specific day and time preference, please provide the details below:

    Day:
    Time:

    Note: We strive to accommodate all scheduling preferences to the best of our ability. By providing specific days and times, we can better tailor our availability to meet your needs.

  • For follow-up on your counseling request, how would you like the office staff to reach out to you?:*

  • By submitting this form, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Isabel Vee Counseling harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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