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
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First Name
Last Name
Client's Date Of Birth
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Month
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Day
Year
Date
Contact Name (if different than client)
First Name
Last Name
Contact Phone Number
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Please enter a valid phone number.
Contact Email
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example@example.com
Preferred Contact Method
Phone Call
Email
Text Message
By entering your phone number, you agree to receive text messages from Renew Hope and Healing. Message and data rates may apply. Message frequency varies. Reply HELP for help or STOP to cancel. View our Privacy Policy https://renewhopeandhealing.com/privacy-policy and Terms of Service https://renewhopeandhealing.com/terms-and-conditions. 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
Are you seeking therapy for yourself or your child because you have been told that you must by a judge, lawyer, or CPS caseworker?
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Yes
No
*Important Note On Mandated Treatment
Unfortunately, Renew Hope and Healing does not offer therapy to individuals that are mandated to treatment by the legal system. We recommend that you consider seeking care through your county mental health clinic or through a larger organization such as the University of Rochester or Rochester Regional healthcare systems.
Do you intend to ask your therapist for documentation or letters supporting a disability application now or in the future?
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Yes
No
*Important Note On Disability
Renew Hope and Healing does not manage or process Social Security Administration (SSA) Disability Determination applications or participate in the SSA mandated Disability Determination. We cannot submit letters or documentation for disability claims. While our therapists are trained to diagnose and treat mental health conditions, most are not trained to assess disability based on legal standards or make recommendations about your ability to work. We recommend you seek care from another practice that does assist in the disability application process.
Are you seeking therapy mostly for concerns about alcohol or drug use?
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Yes
No
*Important Note On Substance Abuse
Most Renew Hope and Healing therapists are trained to treat mental health conditions but not substance use disorders. If you are seeking therapy mostly for concerns about alcohol or drug use, we recommend that you search for care through the OASAS Provider and Program Search https://webapps.oasas.ny.gov/providerDirectory/index.cfm?search_type=2 . If you are seeking therapy primarily for mental health concerns and your therapist assesses that you have an additional substance use disorder that they are not qualified to treat, they may require that you obtain outside treatment for substance use in order to continue your mental health therapy at Renew.
Are you seeking therapy mostly for concerns about eating, including significantly restricting your calorie intake or bingeing and purging?
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Yes
No
*Important Note On Eating Disorders
Eating disorders are some of the most physically dangerous mental health conditions. While Renew Hope and Healing has a few therapists trained to treat eating disorders, our setting is not equipped to provide specialized, high intensity treatment when an eating disorder is causing medical problems. If your therapist assesses that you have an eating disorder that is not safe to treat in our setting, they will refer you to specialist care. If you believe that you may have an eating disorder, we recommend contacting The Healing Connection https://www.thehealingconnectioninc.org/ for an evaluation.
Are you seeking therapy due to strange or unexplainable events, such as hearing voices that others do not hear or seeing things that others do not see, someone or something outside of you controlling your thoughts, or being targeted or followed by a person or people that most other people in your life don't see as a threat?
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Yes
No
*Important Note On Psychosis
These experiences are sometimes symptoms of psychosis. If you have not already spoken with a psychiatrist or psychiatric nurse practitioner, we recommend consulting with a psychiatric provider before seeking therapy at Renew Hope and Healing. Most of our therapists are not trained to treat psychosis spectrum disorders in an outpatient setting and will refer you to other psychiatric and therapy resources if they assess that you are experiencing psychosis.
Have you experienced thoughts about killing yourself, made a suicide plan, or intentionally injured (ex: cut, burned, broken a bone) or attempted to kill yourself in the last 6 months?
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Yes
No
*Important Note On Suicidal Ideation
Most therapists at Renew Hope and Healing are trained to treat suicidal ideation and self injury. However, because these experiences pose significant risk to your physical health, we do require that you attend your initial session in person and maintain your availability to meet in person if your therapist decides that telehealth sessions are not an effective treatment strategy for you.
If you are a parent or guardian seeking therapy for your minor child, does your child have another parent or guardian?
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Yes
No
*Important Note For Parents/Guardians
For ethical and legal reasons, Renew Hope and Healing requires contact information for both parents or guardians, as well as signed informed consent for treatment from both parents or guardians if you are not married. Our therapists cannot ethically or legally exclude a parent or guardian from their child's care unless we have written documentation demonstrating that only one parent has sole custody or medical decision making rights. You will be asked to provide the other parent or guardian's contact information or to provide documentation that they do not have rights to consent to treatment. If you do not provide this information and there is ever a dispute between you and your child's other parent or guardian about their care, your child may be discharged from therapy.
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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)
Aetna
MVP
Fidelis
Martin's Point
United / Optum
Beacon
Tricare
Medicare
Other
Subscriber ID of your insurance
*Important Note On Medicare
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?
Telehealth
In office
I 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 14534
Penfield - 441 Penbrooke Drive Suite 1 Penfield, NY 14526
Henrietta - 755 Jefferson Rd. Suite 4A, Rochester, NY 14623
Victor - 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)
Anxiety
Depression
Grief
Trauma
ADHD / ADD
Relationship Issues
Other
Anything else you are experiencing or need support with? (select all that apply)
Anger Issues
Behavioral Issues
Christian Counseling
Chronic Pain
Court or Custody Issues
Domestic Abuse
Eating Disorder
Family Issues
Intellectual Disability
LGBTQAI+ Issues
Life Transitions
Men's Issues
Mood Disorder
OCD
Postpartum
PTSD
Sexual Abuse Victim
Substance Abuse
Women's Issues
Please provide us with any other information you believe would be helpful
How did you hear about Renew Hope and Healing?
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Word of mouth (friends/family)
My college or school
Google search
My doctor or health care provider
My Health Insurance provider
I'm a former client
Psychology Today
Facebook
Instagram
My employer
Psychiatric Emergency
My case manager
Other
Name of the practice that referred you?
Name of the college or school that referred you?
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