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)
First Name
Last Name
Name of Client (if Minor)
First Name
Last Name
Phone Number (Primary Contact)
Please enter a valid phone number.
Select the applicable age category for the person needing an appointment:
Under 12
12-18
19+
Age of Person Scheduling
Email (Primary Contact)
example@example.com
Email (Secondary, if applicable)
example@example.com
Date of Birth (Intended Client)
-
Month
-
Day
Year
Date
Insurance & Self Pay Options
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
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
Choose a file
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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)
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)
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?)
Submit
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