Appointment Request Form
Still Move Counseling wants to help you or your family member get scheduled quickly! In order to do so, please fill out this HIPPA-Compliant Form, providing the following information so we can follow up with you about our available clinicians and the best fit for your needs.
Name (Primary Contact or Parent/Guardian)
*
Legal First Name
Legal Last Name
Name of Client (if Minor)
Legal First Name
Legal Last Name
Select the applicable age category for the person needing an appointment:
Rows
Under 12
12-18
19+
Age of Person Scheduling
Date of Birth (Intended Client)
*
-
Month
-
Day
Year
Date
Phone Number (Primary Contact)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email (Primary Contact)
*
example@example.com
Email (Secondary, if applicable)
example@example.com
Insurance & Self Pay Options (Select all that apply)
*
Insurance benefits are a MUST
I am open to self pay options, $85/session
I am open to self pay options, $115/session
I am open to self pay options $150/session
I am open to EMDR Intensive Therapy (2hr+, $450+)
My Insurance is Medicaid (or Managed Medicaid: UHC Community, Healthy Blue, Home State Health)
*
Yes
No
No, I plan on self-pay.
Please select your Primary Insurance Provider
*
Please Select
Self-Pay
UHC
UMR
Aetna
Medica
Cigna
Anthem/BCBS
Medicare
Medicaid
Other (Please fill out next field)
If "other," please name your primary insurance provider:
Please provide the following: 1) Full Legal Name of the client to be receiving services. 2) If intending to use insurance, your insurance provider's name.
Please upload a copy of the front of your insurance card & any additional/supplemental coverage.
Browse Files
Drag and drop files here
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I want to schedule the following type of session (virtual/in-person/location):
Please Select
Telehealth
In person, Creve Coeur
In person, Tower Grove
Either Telehealth or In Person Creve Coeur
Either Telehealth or In Person Tower Grove
I was referred for a specific type of therapy.
Please Select
NO specific type referred for
EMDR (Trauma Therapy)
DBT (for emotion/behavior dysregulation)
EMDR Group for Parents
EMDR Group for Betrayal & High Conflict Partners
Other
I was referred for a specific type of therapy
No specific therapy
DBT (for emotion/behavior dysregulation)
EMDR (individual counseling)
EMDR Extended Sessions
Group EMDR for Parents
Group EMDR for Betrayal & High Conflict Partner/Co-Parent
Availability for appointments (choose all that apply)
Monday, daytime (8a-2p)
Monday, late afternoon (2p-5p)
Monday, evening (5p and on)
Tuesday, daytime (8a-2p)
Tuesday, late afternoon (2p-5p)
Tuesday, evening (5p-on)
Wednesday, daytime (8a-2p)
Wednesday, late afternoon (2p-5p)
Wednesday, evening (5p-on)
Thursday, daytime (8a-2p)
Thursday, late afternoon (2p-5p)
Thursday, evening (5p-on)
Friday, daytime (8a-2p)
Friday, late afternoon (2p-5p)
Friday, evening (5p-on)
Saturday Morning/early afternoon ($500/two hour extended sessions)
Is there any additional information you would like us to know? (For example, symptoms or issues you want addressed in counseling, a specific counselor you were referred to?)
I would like updates from Still Move Counseling about services.
Yes, the email listed above will be the email used.
No
Submit
Should be Empty: