Intake Form for appointments

Therapy Request Form - Ellie Mental Health

By completing this form, you consent to have our team leave 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 2 business days.
Which Clinic are you seeking an appointment
Name

First Name of the person entering this formLast Name of the person entering this form
Is the person seeking services a minor?
Date of Birth

MonthDayYear
DOB of the person requesting an appointment
Sex
Pronouns
eg., he/him, she/her, them/they
Phone Number
Please enter a valid phone number of the person entering this formFormat: (000) 000-0000.
Email
Please enter the email - example@example.com of the person entering this form
Are you following a provider who is moving to Ellie?
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?
Name of the Insurance company
How did you hear about us?

Other
Please verify that you are human
Should be Empty:

Therapy Request Form - Ellie Mental Health