Appointment Request Form

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Thank for your interest in therapy services at Evolution Counseling Suite!

Please complete and submit this form AND schedule your free phone consultation. The link to schedule your consultation will be provided in the confirmation message when this form is submitted.

We will get back to you in 1-2 business days.

**Please do NOT complete this form if you are experiencing an emergency/urgent situation. Please call 911 or go to the nearest emergency room immediately.**

Our website: https://www.evolutioncounselingsuite.com/

Name (First and Last) *

Best Contact Phone Number *

Email Address *

All sessions are conducted virtually via a secure telehealth platform (no in-person sessions are available). Are you okay with virtual sessions? *

Yes

You must be physically located in New Jersey or New York throughout the duration of each session. Do you live and/or work in NJ or NY or are you otherwise able to be physically located in NJ or NY for your sessions? *

Yes

PLEASE NOTE:

- We are in network with most commercial Aetna and Horizon BCBS plans (for individual therapy only). We do not accept any other commercial plans or Medicare or Medicaid plans of any kind.

- If you do not have an Aetna or Horizon BCBS commercial plan, your services will be out of pocket/self pay. (We can provide a special insurance receipt called a superbill that you can submit to your insurance company for possible out of network reimbursement).

- We do NOT accept insurance for couples therapy.

- Our per session rates are:

- $225 - individual therapy intake session

- $195 - individual therapy session

- $295 - couples intake session

- $250 - couples therapy session

Do you understand and agree to the above?

Yes

How do you plan to pay for your therapy services? *

Aetna commercial insurance plan (individual therapy ONLY)

Horizon BCBS commercial insurance plan (individual therapy ONLY)

Out of pocket/self pay

Which service are you looking for? *

Individual therapy

Couples therapy

COUPLES THERAPY ONLY: Please share your partner's first and last name, email address, and phone number.

Type N/A if you are looking for individual therapy.

Please share what you would like to work on in therapy.
*

Please share your availability for sessions

(examples: Wednesday anytime, Tuesday to Thursday 12-2pm). Please list all days and timeframes that you are available. If you have open availability with few or no restrictions, please note that.

Sessions are available Tuesday to Thursday only.

How did you hear about us? *

I am a former client

Psychology Today

Therapy for Black Girls

Mental Health Match

Insurance plan directory

Google search

Our website

Social media

Referral from family/friend/colleague

Referral from another healthcare provider (e.g., psychiatrist, therapist, primary care physician)

Referral from another professional (e.g., lawyer)

Other:

IMPORTANT NEXT STEP - PLEASE READ

The next step in the process is to schedule your free phone consultation. This is a chance for us to briefly get to know each other, discuss what you are looking for in a therapist, and determine if we would be a good fit to work together.

The link to schedule your consultation will be provided in the confirmation message when you submit this form.

If you have any questions and/or do not see a time that works for you, please email office@evolutioncounselingsuite.com.

I understand that I need to use the link provided on the next page to schedule a consultation in addition to completing and submitting this appointment request form.

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