Therapy Request Form - Ellie Mental Health
By completing this form, you consent to have our team a generic voicemail and email offering more information. No specific information regarding your request will be included within the voicemail or email.
To request an appointment, please complete the following form. A member of the Ellie Client Access team will be in touch within 1-3 business days.
Name
*
First Name
Last Name
Is the person seeking services a minor?
Yes
No
Pronouns
Please Select
he/him
she/her
they/them
Sex
Please Select
Male
Female
Other
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Please provide a brief summary describing your goals in therapy or the type of support or services you are seeking.
*
Would you like to use insurance?
*
Yes
No
Please select commercial Insurance that you would like to use.
*
Aetna/Luminare
Blue Cross/Blue Shield
Cigna /Evernorth
Highmark BCBS
Independence BCBS
Personal Choice
Keystone Health Plan East
Medicare
Optum
How did you hear about us?
*
Internet Search (Google)
Friend or Family Member
Another Provider (ie.Doctor, case manager)
An online advertisement (Facebook/YouTube)
At a Community Event (ie.resource fair, presentation)
Newsletter
Other
Submit
Should be Empty: