Appointment Request Form
PLEASE NOTE: This form is encrypted to ensure the privacy of your information. Acacia has a business associate agreement with Google that ensures your responses are stored within HIPAA guidelines.

Please complete this form if you wish to be added to our calling list. Any and all information disclosed on this form is confidential and will not be sold or distributed to any third parties with the exception of Insurance billing purposes. Thank you.
Email address *
Office Location *
Name *
Your answer
Phone number *
Your answer
Address *
Your answer
Birth Date *
Student ID Number (Perm Number)
If applicable
Your answer
Please indicate the service(s) you're interested in:
*In an effort to make our services more accessible, we've launched our new platform Reach that offers video therapy services. These sessions are done remotely using a secure platform, and in most cases, can be billed to your insurance as an in-person session would. Signing up for video therapy services may reduce your total wait time. Other benefits include flexible scheduling and having access to a larger network of therapists with varying specialties and backgrounds. If you'd like to learn more, visit
Provider Preference *
Read our bios on our website if you have any questions about our providers!
Referral Source *
Do you give permission to your CAPS referring provider to coordinate initial documentation and scheduling with your Acacia provider?
Further treatment documentation involving non-intake scheduling will need a Request of Information (ROI).
Academic Affiliation *
Class Standing
Availability for Sessions
Please check all times you are available for on each day. Please select times you can consistently make it for at least the current quarter.
9:00 AM
10:00 AM
11:00 AM
12:30 PM
1:30 PM
2:30 PM
3:30 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
Will you be available for appointments during Summer? *
Insurance Information
Please note that if you have Anthem SHIP Insurance, you will need a referral or authorization from CAPS, Student Health.
Health Insurance Provider *
For "Other" insurance, we will most likely be out of network with that carrier. Rates for out of network visits are $150.
ID/Subscriber Number *
Your answer
Do you have a secondary insurance plan? *
Check yes if you are covered by more than one health insurance plan. If you provide incomplete or inaccurate information, you may be responsible for the balances we are unable to collect from your insurance plan(s)
Would you be willing to pay out of pocket for an out of network insurance provider to speed up your scheduling process? Sessions are billed at a $150 rate. *
Many of the clinicians at Acacia are "In-Network" providers, which means they accept your in-network insurance benefits and you are only responsible for your mental health copay. However, new clinicians at Acacia often require time (4-8 months) to get credentialed and be on insurance panels. These clinicians are "Out-of-Network" and bill at a rate of $150. We can still bill these claims to your insurance, and you may or may not have out of network benefits that cover a portion of that rate (We can run an eligibility check prior to scheduling you). These clinicians often have more availability in their schedule because they cannot see as many clients as an in-network provider would be able to. If you are in need of more immediate services and willing to see an out of network provider, please check "Yes" below.
Please check this box to indicate that you read and agree with our Insurance Policy Statement *
If you have an insurance other than Anthem SHIP, please email a copy of your insurance card to so our staff may check your benefits and responsibility before scheduling you.
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