Elevation Counseling New Client Request
Please provide the information below and we will contact you with available therapists and times.

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!
Client's First Name *
Client's Last Name *
Client's Date of Birth *
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Cell Phone Number *
What type of counseling are you seeking? *
What is the general nature of your reason for seeking therapy? *
Email Address *
Primary Insurance Type *
Insurance ID Number or Medicaid# *
Insurance Group # *
Have you ever been hospitalized for a mental health, substance abuse or alcohol condition? *
Are you having any thoughts of hurting yourself or others? if so, please call New Mexico crisis line 24/7 at 1-855-NMCRISIS (662-7474). *
Which type of therapy or specific providers are you most interested in seeing? We provide TELEHEALTH ONLY or telephone as last resort in response to the COVID pandemic and in support of our community safety. Please visit https://www.elevationcounseling.com/counselors-and-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? *
How may we contact you for scheduling? (check all methods that you are willing to receive). *
Required
Please confirm each of the following policies of Elevation Counseling *
Required
How did you hear about 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 have long wait lists. You will receive a confirmation email and offers of available appointments from office@elevationcounseling.com. Please ADD our email to your contacts or check your SPAM folder if you haven't heard from us.
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