Appointment Request Form

New/Returning Client Appointment Request Form

Welcome to Theratel Counseling Services, the Office of Amandia Speakes-Lewis & Associates and thank you for reaching out to our practice. We are happy you have taken the first step in seeking counseling services. Please take a moment to provide some important information to begin the process. This will help us in assigning a therapist to best meet your needs. This information will help us in verifying your insurance and whether you have copays or deductibles. It will also assist in getting an understanding about why you are seeking services at this time. INFO YOU PROVIDE IS STRICTLY CONFIDENTIAL AND ONLY TO VERIFY INSURANCE AND MATCH YOU WITH A THERAPIST. If you have questions you can reach us at 516-341-7094 or email: Theratelcounseling@gmail.com
Today's Date

MonthDayYear
Date
Full Name of Client*

First NameLast Name
What are your pronoun preference:

He/HImShe/HerThey/Them
Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of counseling you are seeking

Individual CounselingCouple CounselingFamily Counseling
When is the best time to reach you to setup an appointment?
Include day and time
Date of Birth*

MonthDayYear
Date
If client is a minor, please provide Parent/Guardian info below

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone number
Please enter a valid phone number.
Are you located outside of New York State*

YesNo
Do you have insurance*

YesNo, I plan to be a self-pay client. We will contact your about session rates
If you have insurance, which do you have?

AetnaAnthemBCBS (Blue Cross Blue Shield Empire BCBS)Carelon Behavioral HealthCignaCigna - EAP (Please provide EAP Code)Empire Plan (Not Empire BCBS)Fed BlueNYSHIP (New York State Health Insurance Plan)Northwell/MagnaCareOscarOxfordUnited Health CareUnited Health Care Medicare Advantage1199
Insurance Member ID# (please provide, even if using your EAP)
Member ID #
Insurance Group # (If applicable)
Insurance Group #
Do you have a copayment or deductible?

YesNo
How much is your copayment or deductible?
Include dollar amount
Please upload a copy of your insurance card (FRONT)

FRONT OF CARD
Cancelof
Please upload a copy of your insurance card (BACK)

BACK OF CARD
Cancelof
EAP Clients, how many sessions have you been approved for?
Number of EAP Sessions
EAP CLIENTS: Please upload a copy of your EAP authorization letter here

Cancelof
If you are having any problems uploading documents, you can email copies to: Theratelcounseling@gmail.com
Is this insurance through an employer or place of employment?

YesNo
What days and times are you available for counseling sessions?
Days and time you can commit to counseling sessions
Are you experiencing any of the following?

AnxietyDepressionPTSDStressSelf harm/suicidal thoughtsRelationship IssuesFamily Conflict
Are you experiencing a mental health crisis?

If you are experiencing suicidal thought or behaviors, or are in any type of mental health crisis, please contact 911 or go to the nearest emergency room immediately. For urgent mental health support, you can call or text the Suicide & Crisis Lifeline at 988 to connect with a trained counselor 24/7. Your safety and well-being are out top priority. This form is not monitored for emergencies.
Tell us in 1 to 2 sentence why you are seeking counseling at this time.
How did you hear about us?

Website/InternetReferred by friendDoctor's OfficeOther
By clicking submit you agree to our office verifying your information. Any questions you can email Theratelcounseling@gmail.com or call 516-341-7094. By sumbitting this form you agree to receive text messages at the the number provided. Standard message data rates apply.
Please verify that you are human*
Should be Empty:

New/Returning Client Appointment Request Form