Appointment Request Form

Appointment Request Form

Please provide the following information
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Preferred method of contact:*
Type of Counseling that you are seeking: *
Appointment is for:*
Name and Age of Spouse and/or Family members included in therapy:
Please include any persons that will be attending sessions that are not yourself.
Availability:*

Mornings (8am-12pm)Afternoons (12pm-4pm)Evenings (5pm-9pm)
HEC Location Requested (you may choose more than one):*

Palos Heights, ILMemphis, TNSouthaven, MSOxford, MSCorinth, MSVirtual/Telehealth
What state are you located in?*
Clinician Requested:
Schedules and caseloads are subject to change, so your requested therapist may not have any current openings. If this is the case, our dedicated staff will provide appropriate alternatives
Referred by:*
If you chose "Healthcare Provider" or "Other", please specify:
What brings you here today? (You may select more than one)*

DepressionAnxiety/Panic AttacksStressPTSD/TraumaDisordered EatingMajor life changesRelationship IssuesCompulsive Thoughts/ActionsGrief/LossIncreased Substance Use/Substance AbuseDivorceMood SwingsParenting IssuesLGBTQIA+ IssuesAnger ManagementPost-Partum Anxiety/DepressionOther
If you chose "Other", please specify:
50 Character maximum
Do you have any previous diagnoses?*
Previous Diagnoses
Are you seeking a specific modality?
Modalities are approaches or methods that a therapist will use to help you reach your goals
Please select all modalities that you are seeking:

CBTDBTTrauma FocusedEMDRIntensive
More information regarding EMDR Therapy and Intensive Therapy can be found here:

EMDR Therapy

Intensive Therapy (Personal Therapeutic Retreats)
Insurance Carrier*
Self-Pay Options:*
Please contact your chosen HEC location for options on Self-Pay rates. Cash, Check, and Charge accepted (Visa/MC/Discover)
Things to know for your appointment:

⦁ Look for a link to My Client's Plus client portal via email. (Check your Spam folder if you haven't received a link within 24 hrs., If your link is not in your Spam folder, please contact your local HEC office)

⦁ Complete ALL intake paperwork on My Client's Plus and be sure to complete ALL required fields and select "Save/Next" (Partially completed documents WILL NOT save).

⦁ If we don't receive your paperwork at least 24 hours before your appointment, you will need to arrive 10 minutes early to complete intake paperwork.

⦁ Bring your insurance card/information, State ID, & payment for services if they have not already been provided. State ID's and insurance cards can be emailed directly to your provider.

⦁ You will receive a confirmation text 48 hours before your scheduled appointment.

Please confirm by replying "1", or reschedule by replying "2".
Should be Empty: