Behavioral Health Appointment Request Form

Behavioral Health Appointment Request Form

Please fill out the form below if you are interested in scheduling an appointment with one of our behavioral health counselors. After submitting this form, you will be contacted from Scenic Bluffs within two business days.
Patient Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Preferred Language

EnglishSpanishOther
How would you prefer to be contacted?

Phone callEmail
What is the best time to reach you?

8AM to 11AM12PM to 2PM3PM to 6PM
Health Insurance

No one will be denied access for lack of insurance. If you do not see your health insurance company listed as an option below, it is likely that we do not have a therapist currently available for appointments that is enrolled with that insurance. This means that your insurance will not pay for services from our therapists. This list may change in the future.
Health Insurance*
Should be Empty:

Health Insurance