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Therapy Request Form (Donovan Individual and Family Counseling Services, Inc.)
Please complete the form below.
* Indicates required question
Email
*
Your email
Are you seeking:
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Telehealth therapy
In-person therapy
Is this for
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Individual Therapy
Couples/Marriage Therapy
Please tell us briefly what is bringing you to counseling:
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Your answer
Name of client (First and last name)
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Your answer
Name of parent if a minor (First and last name)
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Your answer
Main Client's Date of Birth:
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MM
/
DD
/
YYYY
Phone number:
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Your answer
City and State.
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Your answer
Insurance (We currently only accept the insurances on this list).
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Choose
IEHP (Pre-authorization required)
Lyra
Kaiser (Pre-authorization required)
I will be paying out of pocket ($160.00 per 53-Minute Session)
I have Anthem and I would be willing to see an Associate Therapist
I would be willing to pay cash to see an Associate Therapist at a lower fee ($100 per 53-Minute Session)
Insurance name. If Cash pay put "I agree to pay cash for sessions".
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Your answer
If you have insurance
Insurance ID/ Member Number. If cash pay put NA.
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Your answer
Questions or comments (Please also list days and times of your availability).
*
Your answer
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