Elevation Counseling New Client Request - Wait List
PLEASE NOTE: Many of our therapists are currently FULL and we may not have openings for over a month - if you need an immediate appointment, continue reaching out to other agencies and providers, in addition to adding yourself to Elevation's waitlist.

Please provide the information below and we will contact you with available therapists and times to be added to our WAIT LIST.  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!

We DO NOT have openings for children under 13, or couples and we can only provide referrals at this time.    

Sign in to Google to save your progress. Learn more
Client's First Name *
Client's Last Name *
Client's Date of Birth *
Cell Phone Number *
Please enter your Email Address (Also note: Please check spam or add office@elevationcounseling.com to your contacts so you can receive our appointment offers).  We send emails with our openings, by entering your email you acknowledge the inherent privacy risk in email communication *
Email Address
What type of counseling are you seeking? *
Required
Will you be physically located in NEW MEXICO when receiving therapy?  Licensing rules require clients to be physically located in NM to receive services from NM licensed providers. *
Do you want in-person, telehealth, or whichever is available first?  (Note: at this time the vast majority of our therapists are only seeing clients via TELEHEALTH) *
What is the general nature of your reason for seeking therapy? This helps us determine which therapists will be the best fit. *
What mental health / behavioral health insurance do you have? (sometimes your mental health benefits are separate - please check your card)  If Centennial Care/Medicaid please list the specific insurance company.  NOTE: we DO NOT take Medicare, Aetna or Cigna insurance.   If you have Tricare "Active Duty" you NEED a referral before you can be seen. *
Required
Health Insurance Member ID or Medicaid # *
Specific type of therapy or specific providers you are interested in seeing. 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.  NOTE: evening appointments are rarely available and will require a long wait. *
Required
If we do not have any openings for individual therapy, would you be interested in a group therapy option? *
How may we contact you for scheduling? (check ALL methods that you are willing to receive).  We send appointment availability by email, so please list an email address above to which you are comfortable receiving scheduling emails) *
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 in the last year? *
Are you currently experiencing any suicidal thoughts? *
Are you seeking therapy for substance abuse? *
Suicidal thoughts - If you are currently having any suicidal thoughts, 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 (855-662-7474). This form simply adds you to a waitlist and it may be some time before we are able to contact you.
BE SURE TO HIT SUBMIT!  Thank you for sending this information. We will get back to you with any available openings.   Please check your SPAM for emails from office@elevationcounseling.com
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Elevation Counseling. Report Abuse
Google Forms