Appointment Request Form
*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.
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.
Required fields on this form are marked with a red asterisk* Please don't hesitate to submit your form with any blank fields that are not required.

Thank you! We're so honored to be considered for your mental health care!
Email address *
Office Location *
Name *
First and Last Name
Your answer
Phone number *
Your answer
Address *
Include ZIP CODE
Your answer
Birth Date *
Student ID Number
If applicable - This can help us in case we ever need to coordinate with UCSHIP for more information. If you're not sure, you can leave this blank for now
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 *
Referring Provider or Referral Number
If your referral is from the Counseling Center or Student Health, please include the provider's name if you know it. If you're unsure, you can leave this field blank. Go here for more referral info:
Your answer
Do you give permission to your 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
Which days and times are you available?
Your answer
Insurance Information
Please note that if you have a UC SHIP plan, you will need a referral or authorization which can be found online, at your Counseling Center, Student Health, UCSHIP office, or the Alcohol & Drug Program. Go here for more referral info:
Health Insurance Provider *
ID/Subscriber/Policy 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 UC SHIP, please email a copy of your insurance card (front and back) to so our staff may check your benefits and responsibility before scheduling you.
Never submit passwords through Google Forms.
This form was created inside of Acacia Counseling & Wellness.