Appointment Request Form

New Client Appointment Request

Zoetry Counseling Group
Please use this secure form to provide information to help us find the best counselor for you.

Please note we do not accept Employee Assistance Program (EAP) insurance.

If you are an existing client, please click here to sign in to our client portal.
Name*

first namelast name
Phone
provide caregiver's phone for child / teen clients
e-mail*
provide caregiver's email for child / teen clients
Client Date of Birth*

MonthDayYear
Client Gender*
Are you requesting this appointment for someone under the age of 18 years old?*

YesNo
Legal Custody Documentation (if applicable): Do you have a divorce decree, custody agreement, or other legal documentation that outlines your rights to make medical or mental health decisions for your child, including bringing them to therapy?*

YesNo
Please upload a copy of any legal custody documentation. This helps us ensure we are following all legal guidelines regarding your child’s care.*

Cancelof
Preferred Office / Counselor*
Are you seeking EMDR therapy services?*

YesNo

Select the times you are typically available to meet*

Please provide other pertinent information regarding your availability
Can we contact you via text message to schedule your first appointment?*

YesNo
Are you a military veteran or first responder?*

YesNo
Will you be using insurance?*

YesNo
Please note we do not accept
Employee Assistance Program (EAP) insurance.
Insurance Company*

AetnaAnthemBlue Cross Blue ShieldCigna/EvernorthMagellanMultiplanOptumOscarScott and White Health PlanUnited HealthcareUMROut-of-NetworkOther
Insurance ID Number*
Name of Primary Policyholder
If different than yourself
Date of Birth of Primary Policyholder
If different than yourself
Upload insurance card (optional)

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If you are comfortable doing so, please share something about your reason(s) for seeking therapy.
If you are requesting this appointment for someone other than yourself, please provide your name, contact information and describe your relationship to the client.
age
Assigned Counselor
How did you hear about us?*

Google searchInsurance referralPsychology TodayFriend or family memberDoctor referralTherapist referralOther
Preferred Counselor
Source
SubmissionDate

MonthDayYear
SubmissionDate
SubmissionTime

Hour Minutes

AM/PM Option
Submission Date / Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

New Client Appointment Request