ECMC Client Appointment Request Form

ECMC Appointment Request Form
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Is the client a minor?
Name of parent or guardian

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Insurance Provider
Insurance ID Number
Does your insurance require a co-pay?
Co-pay amount
Insurance Card (Optional)

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Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Seeking Counseling
Group Counseling Topic
Parole Officer Name
Parole Officer Email
example@example.com
Parole Officer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parolee Release of Information

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Other/ additional background:
Prescription Services/ Psychiatric Care are provided through our virtual partner agencies. To request or schedule an appointment, please complete the forms through their portals as well.

For Fulton Family Psychiatry:

https://www.fultonfamilypsychiatry.org/appointments

For Green Wellness

https://form.jotform.com/Green_Wellness/med-management-intake

For Timothy Greco, NP (Commercial plans only)

https://www.timgreconp.com
Preferred Timeframe for Sessions
Provider Preference
Provider Gender Preference
Preferred Counseling Method
How did you hear about us?
Upload any pertinent documents that you would like your provider to review.

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Who completed this form?

Other
Discharge Planner Email
example@example.com
Are you referring a client for follow-up after a hospitalization?
Appointment Preference (Appointments must be made within 7 days of discharge)

MonthDayYear
Date
Hour MinutesAM/PM Option
Were you assigned a peer?
Peer Name
Peer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

ECMC Appointment Request Form