Therapy Session Request Form
Information you provide on this form will help us find you the best therapist match. By completing this form, you consent to have our team leave a generic voicemail and email offering more information. Please email us if you need more information: EllieNJ14601@elliementalhealth.com
Person Seeking Therapy
State Where You Seek Therapy
*
Please Select
New Jersey
Our clinics provide therapy only in the state of New Jersey.
Name
*
Age
*
Date of Birth
*
-
Month
-
Day
Year
Insurance: We cannot accept Medicaid or EAP.
Please Select
Aetna (excluding "Aetna Better Health")
Horizon BCBS (excluding "Horizon NJ Health")
Blue Cross Blue Shield
Optum
Oxford
United/UHC (excluding "Community Plan")
Cigna
Medicare
AmeriHealth
Tricare
Multiplan
Upload Front of Insurance Card
*
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of
Upload Back of Insurance Card
*
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of
Preferred Therapy Location
*
Please Select
Telehealth Only
Basking Ridge (222 Mt Airy Rd)
Morristown (26 Madison Ave)
Parsippany (10 Lanidex Plaza West)
No preference
Contact Email
*
Contact Phone Number
*
Please provide a brief summary describing your goals or the type of services and therapist you are seeking:
*
Guardian/Inquirer For Person Seeking Therapy
If Different From Person Seeking Therapy
Guardian/Inquirer Name
If different from person seeking therapy
Contact Phone Number
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