Aspire Counseling Appointment Request
Please answer the following questions. We will get back to you with an appointment or call you for more questions.
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Patient's Name *
If a minor, who is the parent or guardian?
Date of Birth:
(Note: We only see clients 13+)
*
MM
/
DD
/
YYYY
Phone Number (Patient, Parent or Guardian) *
Email Address *
Primary Insurance *
Secondary Insurance
Do you prefer: *
How did you hear about us or who referred you?
Availability (Check All That Apply) *
Required
Please list an Emergency Contact, their Phone Number, Address and Relationship to you. *
Why are you seeking therapy at this time? What life event or circumstance may have prompted therapy now? *
Please list any Mental Health Diagnoses you have been given or believe you have. *
Please list any Alcohol or Substance Use Disorders you have been given or believe you may have. *
List Any of the following: 
Psychiatric Medications you are taking
Prescribing Doctor 
Other therapists you are working with.
Name and location of your Primary Care Provider (requested per insurance requirements).
Legal: Please choose the drop down that most accurately describes your legal status. *
Please list any current or history of Suicidal Thoughts *
Please list any current or history of thoughts to harm someone else. *
Please check any/all of the programs you have attended in the last 6 months. *
Required
Is there any other information we need or should know?
Please allow 24 business hours for staff to be in touch with you. If you need more immediate attention please dial 911 or head to your nearest emergency room.
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