Elevation Counseling New Client Request
Please provide the information below and we will contact you with available therapists and times, we will get back to you soon. 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!
Client's First Name *
Client's Last Name *
Client's Date of Birth *
Cell Phone Number *
Email Address (preferably Gmail because we use Google Meet for telehealth sessions) *
What type of counseling are you seeking? *
What is the general nature of your reason for seeking therapy? *
What health insurance do you have (if any) (BCBS, United, Presbyterian ,Etc. )? *
Health Insurance Member ID or Medicaid # *
If there is a specific type of therapy or specific providers you are interested in seeing. If so please add that info here. You can check mulitple boxes and list specific therapists in the "other" box. *
Required
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. *
Required
How may we contact you for scheduling? (check all methods that you are willing to receive). *
Required
Please confirm each of the following policies of Elevation Counseling *
Required
Have you been hospitalized or undergone in-patient treatment for any mental health issue or suicidality? *
BE SURE TO HIT SUBMIT! Thank you for sending this information. We will get back to you shortly about scheduling your first appointment.
Submit
Never submit passwords through Google Forms.
This form was created inside of Elevation Counseling. Report Abuse