Appointment Request

Appointment Request

To request an appointment you can call 585-398-8835 or use this form below. Please allow one business day to get back to you. Please note: This form is not for current clients. Current clients please call 585-398-8835 or email hello@renewhopeandhealing.com to change/reschedule appointments.
Client's Full Name*

First NameLast Name
Client's Date Of Birth*

MonthDayYear
Date
Contact Name (if different than client)

First NameLast Name
Contact Phone Number*
Please enter a valid phone number.
Contact Email*
example@example.com
Preferred Contact Method

Phone CallEmailText Message
Renew Hope and Healing complies with HIPAA and wants to exchange text messages with you. Text messaging may not be fully secure. To consent, check the box below

I consent to exchange text messages
If you are using insurance to pay for any portion of services, please indicate below. NOTE: We do not take Medicare Primary

Excellus BCBS (including Blue Choice Option, Medicaid)AetnaMVPFidelisMartin's PointUnited / OptumBeaconTricareMedicareOther
Subscriber ID of your insurance
MEDICARE NOTE

We are not currently able to accept Medicare Parts A and B. We have limited availability for Medicare Advantage plans.
If you have a specific clinician you are seeing or would like to see, please put their name here
Do you have a preference for an in-office or telehealth appointment?

TelehealthIn officeI am open to either
Which office(s) would you prefer to see your therapist (select all that apply)

Pittsford - 90 Office Park Way Pittsford, NY 14534Penfield - 441 Penbrooke Drive Suite 1 Penfield, NY 14526Henrietta - 755 Jefferson Rd. Suite 4A, Rochester, NY 14623Victor - 6539 Anthony Dr. Suite A, Victor, NY 14564
Preferred appointment day of the week and/or time of day?
To help us match you with the right therapist, please let us know if you are experiencing any of the below (select all that apply)

AnxietyDepressionGriefTraumaADHD / ADDRelationship IssuesOther
Anything else you are experiencing or need support with? (select all that apply)

Anger IssuesBehavioral IssuesChristian CounselingChronic PainCourt or Custody IssuesDomestic AbuseEating DisorderFamily IssuesIntellectual DisabilityLGBTQAI+ IssuesLife TransitionsMen's IssuesMood DisorderOCDPostpartumPTSDSexual Abuse VictimSubstance AbuseWomen's Issues
Please provide us with any other information you believe would be helpful
How did you hear about Renew Hope and Healing?*

Word of mouth (friends/family)My college or schoolGoogle searchMy doctor or health care providerMy Health Insurance providerI'm a former clientPsychology TodayFacebookInstagramMy employerPsychiatric EmergencyMy case managerOther
Name of the practice that referred you?
Name of the college or school that referred you?
Should be Empty:

Appointment Request

MEDICARE NOTE