Appointment Request Form
Let us know how we can help you!
Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What services are you interested in? Are you scheduling for yourself or someone else? Is there a specific therapist you are hoping to schedule with? Please provide as any other relevant details.
If you'd like to see if we can accept your insurance for sessions, please enter the following below: 1. The name of your insurance, 2. Your insurance member ID number/letters, 3. Your insurance group number/letters, 4. Your date of birth
How did you hear about us/who referred you to us?
I understand that this form is for inquires and is not a guarantee of scheduling or services. I understand that a staff member of Ellie Mental Health [Southlake, Flower Mound, Southwest Fort Worth locations only] will contact me directly via email or phone to further discuss availability for scheduling as well as if there is a good therapist match to work together. *Ellie Mental Health does NOT accept Medicaid or Medicare at this time and is OON only with Tricare.* I consent to allow Ellie Mental Health to contact me via phone call, text and/or email in response to this request. Please type your full name in the box below to acknowledge and agree to this understanding.
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