Magothy River Counseling
info@magothyrivercounseling.com
Individual Therapy Request Form
We know that finding a therapist is hard. Whether thats because you don't get a call back - or, they weren't the right fit. If you'd like to set up a therapy appointment, please complete the form below and our client care coordinator will reach out to you for any additional information. We respond to inquiries Monday-Thursday.
Client's Name
*
First Name
Last Name
Client's Pronouns
*
(She/Her, They/Them, He/Him, etc)
Date of Birth
*
-
Month
-
Day
Year
We are not accepting clients 16 and younger. We accept clients age 17+ pending goodness of fit, and therapist availability.
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Please Select your Primary Insurance Carrier:
*
Please Select
Aetna
Blue Cross Blue Shield / Carefirst
Carefirst Administrators
Cigna / Evernorth
United Healthcare (Commercial) / UHC / UBH / GEHA
Hopkins EHP or USFHP
Tricare* (Certified OON Provider)
Out of Network: Kaiser
Out of Network: Medicaid
Out of Network: Medicare
Out of Network: ComPsych
OTHER : OUT OF NETWORK
select the best answer for you
Preferred Method of Contact:
*
Please Select
Email
Phone (okay to leave voicemai;)
Phone (NOT OKAY TO LEAVE VOICEMAIL)
Phone (okay to LVM) OR EMAIL
Phone (Do Not LVM) OR EMAIL
You can select availability on the next page
Primary reason for seeking therapy
*
Please Select
ADHD
Autism
AuDHD
Anxiety
Bipolar
Depression
Trauma/PTSD
C-PTSD
Grief/loss
Relationships
Family of Origin issues
"Adult Child of ____"
LGBTQIA Affirming Care
Sex Therapy/Sexual Health
Other
Briefly: Help us understand why you are seeking therapy
*
This form is not as substitute for medical care. If this is a life-threatening or medical emergency, please visit your nearest Emergency Room or call 911. We are not able to monitor this form for emergencies. Licensed therapists are mandated reporters for present and past imminent risk to self or others, abuse, and neglect.
Preferred Therapist:
*
Please Select
NEXT AVAILABLE
C Sailer LCPC (No BCBS HMO)
Morgan Cregan LCPC
Meghan Powers LCPC
Lisa Muscato LCPC (No BCBS HMO)
Julie Meyers LCPC
David Christy LCPC PhD
Bradley Spoon LCPC
I'd like to work with a male provider
I'd like to work with a female provider
I'd like to work with a non-binary or gender diverse provider
I have no preferences
Other:
Not all therapists are eligible to except all insurance plans. None of our therapists have evening availability.
I feel like i NEED a 15-minute consultation before the initial appointment
*
Please Select
Yes
No
Initial consultations are offered as a courtesy, and their availability is subject to change. They are for "making sure the therapist feels like a good fit". They are NOT therapy. In our experience, if a therapist feels like a good fit, they likely are. And, if they end up not being the correct fit after the intake we will help you choose a therapist with our company, or an outside provider who will help
Availability:
Select ALL the times that MIGHT POSSIBLY work for you. We do our best to accommodate based on your availability and our open availability, which is subject to change. AT THIS TIME WE DO NOT HAVE EVENING APPOINTMENTS.
Mondays
9-11
11-1
1-3
3-5
I need an evening appointment
none
Tuesdays
9-11
11-1
1-3
3-5
I need an evening appointment
none
Wednesdays
9-11
11-1
1-3
3-5
I need an evening appointment
none
Thursdays
9-11
11-1
1-3
3-5
I need an evening appointment
none
Fridays
9-11
11-1
1-3
3-5
I need an evening appointment
none
Consent to follow up via Email:
By submitting this form, you agree to allow us to use the email address provided for future communications. These communications may include our practice newsletter, updates, or promotional offers, and other information related to our products and services. You can opt-out at any time by clicking the unsubscribe link in the emails you receive from us. Your email address will be kept confidential. Your consent to receive marketing communications is voluntary, and you can withdraw it at any time.
Contact Us:
If you have any questions please feel free to contact us via email: info@magothyrivercounseling.com or through our website http://www.magothyrivercounseling.com/contact-us
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