Elevation Counseling New Client Request
Please provide all information so we can begin the appointment scheduling process. All information is stored in a confidential, secure, HIPPA-compliant digital location. We will confirm your insurance eligibility and any related co-payments, deductibles or any limitations on behavioral health care. We will contact you back with our therapists' availability.

Be sure to hit "SUBMIT" at the bottom of the form!

First Name (if seeking therapy for your child please enter their information) *
Your answer
Last Name *
Your answer
Date of Birth *
Your answer
Cell Phone Number *
Your answer
What type of counseling are you seeking? *
What is the general nature of your reason for seeking therapy? *
Your answer
Email Address *
Your answer
Primary Insurance Type *
Insurance ID # *
Your answer
Insurance Group # *
Your answer
Which providers are you most interested in seeing? (visit https://www.elevationcounseling.com/office-staff/ to read about our counselors) *
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: Evenings are frequently full and will have a wait list for most therapists.) *
Required
If your preferred times and/or therapists are full would you like to be placed on a wait list? *
Preferred contact method(s) for scheduling *
Required
Please confirm each of the following policies of Elevation Counseling *
Required
How did you find Elevation Counseling? *
Thank you for submitting this information. We will get back to you shortly about scheduling your first appointment. The more flexibility you have the sooner we will be able to get you in. Note: evening appointments are very popular and often full.
Submit
Never submit passwords through Google Forms.
This form was created inside of Elevation Counseling.