Counseling Appointment Request Form

Counseling Appointment Request Form

Isabel Vee Counseling
Please fill out the form below to request an appointment.
Client Legal Name*

First NameLast Name
Client's Preferred Name:
e.g. nickname, NA, etc
Client's Phone Number*

Area CodePhone Number
Email Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Age:*
What is your age today?
Sex (legal sex)*
Are you a NEW or RETURNING client??*
Please SELECT the THERAPIST you would like to see:*
If you are a RETURNING client, approximately when was the last time you participated in counseling with Isabel Vee Counseling?
N/A if appropriate
Referral Source: How did you find Isabel Vee?*
Other Referral Source NAME:

Requested Services

You can select more than one service.
I'm interested in a counseling or consulting appointment for (If on a computer, press Ctrl to select more than one option). Please select at least ONE option. It is important that we know what your reason is for seeking counseling:*
Please choose at least one option. Press Ctrl to select more than one option. Scroll to the end of the list for non-clinical (coaching) appointment requests.
**Please note we primarily provide Individual Counseling for Adults (18 yo+). However, three of our counselors see ages 14+
What type of counseling are you seeking?*
What led you to consider therapy today? Has anything recently occurred in your life that prompted you to seek counseling at this time?*
**Please provide some detail as to why you are seeking counseling.
How do you plan on paying for counseling services?*
If using EAP Benefits, please indicate which company (SKIP if not using EAP):

Optum Live and Work WellCigna EAPAetna EAPMagellan EAPOther

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.
Client's Full Legal Name (on insurance card)*

First NameMiddle NameLast Name
Insurance Provider (If applicable).*

BCBS (Blue Cross Blue Shield)United HealthcareAetnaCignaBaylor Scott and White (BSW)Magellan (BCBS Behavioral Health Provider)Not Applicable/No insuranceNA - Using EAP benefitsOther
- If you have already provided insurance information on a different platform such as ALMA or Headway, you do not have to provide this information again. Just enter NA
- If you cannot provide at this time, or don't have your insurance information available, please enter NA
Insurance ID #*
Group # (if applicable)
Upload photo copy of Insurance Card (optional)

Upload Files

Cancelof
Client's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pre-screening
Have you ever participated in therapy before? If so, when was the last time? If you recently participated in therapy (within the past 6 months), please explain why you are searching for a new Therapist.*
Are you CURRENTLY experiencing suicidal thoughts? If YES, do you have a plan and/or intent to harm yourself?*
Indicate Yes or No
Are you CURRENTLY experiencing homicidal thoughts (harm to others)?*
Indicate Yes or No
Are you currently experiencing anxiety, panic attacks or have any phobias? If so, how long have you been experiencing these symptoms?
Are you experiencing any symptoms of depression (sadness, hopelessness, irritability, low motivation, etc). If Yes, please explain how long you have been experiencing these symptoms?
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?*

Telehealth - VideoTelehealth - TelephoneIn-personEither Telehealth or in Person (No preference)
When are you hoping to have sessions*
At the start of services, please specify your preferred session times. When are you hoping to have sessions? (Select all that apply):*
Specific Day and Time (if applicable):

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

Day: blanks
Time:blank

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?:*

EmailTextPhone (talk)No preference (If no preference, the Therapist will use email or text)
If our administrative staff have any questions or need to follow up on your counseling request, when is the best time to contact 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.
Should be Empty:

Abuse (sexual, physical)
Academic Issues
Addiction & Substance Abuse
ADHD
Anxiety
Attachment issues
Bipolar Disorder
Career Coaching
Chronic health conditions
Co-dependency
Couple's Counseling/Marriage Counseling
Depression
Diagnostic Assessment
Divorce /Separation
Domestic Violence/Family Violence
Grief and loss
Infertility Issues
LGBTQIA+
Life transitions
Obsessive Compulsive Disorder/OCD
Panic/Anxiety disorder
Parenting
Phobias
Post Traumatic Stress Disorder/PTSD
Postpartum Anxiety
Postpartum Depression
Premarital counseling
Relationship difficulties
Self-esteem and Self-image
Self-harm/cutting
Sexual Assault/Violence
Sleep Issues/Insomnia
Suicidal Ideation/Attempt
Work-Life Balance
Other (EXPLAIN BELOW)
Other: Clinical Supervision (LMSW)
Other: Career Coaching/Consulting
Other: Interview for school assignment
Other: Interview for media
Other: Social Work student educational consulting

Counseling Appointment Request Form

Please fill out the form below to request an appointment.

Requested Services

**Please note we primarily provide Individual Counseling for Adults (18 yo+). However, three of our counselors see ages 14+

Insurance Information

To expedite scheduling, please provide the following information.

Pre-screening

Sessions