Elevation Counseling Medication Management Appointment Request - Telehealth
Please provide the information below and we will contact you about scheduling a Medication Management or Psychiatric Evaluation appointment.  BE SURE TO HIT SUBMIT at the bottom of the form.    

If you are filling this out for a child, please input the child's information not your own.  

Please add office@elevationcounseling.com to your contacts, or check your spam folder often, as our appointment emails can sometimes get screened out!

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Are you currently an Elevation Counseling client or will you be a new client to Elevation Counseling? *
Client's First Name *
Client's Last Name *
Client's Date of Birth *
Cell Phone Number *
Email Address (we will contact you by email - only list an email to which you agree to receive scheduling communication. By agreeing to email communication you acknowledge and accept the inherent privacy risk of email communication) *
What is the general nature of your reason for seeking Medication Management or Psychiatric Care? At this time we DO NOT have providers who treat adult ADHD.   *
Health Insurance Member ID or Medicaid # *
What health insurance do you have (if any) (BCBS Centennial Care, BCBS PPO / HMO,  Presbyterian Centennial Care, Presbyterian PPO, United Health, UMR, Western Sky, Molina,  Tricare, Medicaid, Etc. )? We do NOT take Medicare, Cigna, or Aetna.   *
Let us know if you have certain days or times you need to schedule your appointments. If you are flexible (great!) please check the "I'm Flexible" option. *
How may we contact you for scheduling? (check all methods that you are willing to receive). *
Please confirm each of the following policies of Elevation Counseling *
Are you currently experiencing suicidal thoughts? If so please call 911 or the New Mexico Crisis And Access Line as soon as possible. They are available anytime 24/7/365 1-855-NMCRISIS (662-7474). This form simply adds you to a waitlist and it may be some time before we are able to contact you. *
Have you recently been released from in-patient care or hospitalization? *
BE SURE TO HIT SUBMIT!  Thank you for sending this information. We will get back to you shortly about scheduling your first appointment.  
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