Counseling Intake Request- F.A.M Healing Center

Counseling Intake Request- F.A.M Healing Center

Please complete this form to request outpatient mental health counseling services at F.A.M Healing Center. Our intake team will review your information, verify insurance or self-pay arrangements if applicable, and contact you to schedule your appointment.This form is not monitored for emergencies.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*

Confirmation EmailConfirm Email
Phone Number*
Please enter a valid phone number.
What City are you located in?*
Las Vegas (In-Person)Pahrump (In-Person)Telehealth (Nevada Residents Only)
Individual CounselingCouples CounselingFamily CounselingFaith-Based CounselingEquineAssisted Therapy
AnxietyDepressionTrauma/PTSDStress/BurnoutRelationship concernsFamily IssuesLife transitionsGrief/LossSubstance AbuseOther
InsuranceSelf-Pay/Private PayEAP
Insurance Information
Insurance Carrier
Member ID or Authorization Reference Number for (EAP)
Upload Governmental ID*

Cancelof
Upload Insurance Card or EAP Referral

Cancelof
Self-Pay Counseling
Any question regarding self-pay or fees?
NoYes
If you are experiencing thoughts of harming yourself or others, please seek immediate help.

Call 911, go to the nearest emergency room, or contact the Suicide & Crisis Lifeline by calling or texting 988.
Please share your general availability or preferred days/times for appointments.
SelfCourtAttorneyWebsiteInsurance CompanyOther
I understand this form is a request for services and does not guarantee an appointmentI consent to be contacted by F.A.M Healing Center regarding counseling servicesI confirm I am seeking outpatient Mental Health or Substance Use Therapy services
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Counseling Intake Request- F.A.M Healing Center

Insurance Information

Self-Pay Counseling