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)
Date of Birth
Cell Phone Number
What type of counseling are you seeking?
Individual therapy for an adult
Individual therapy for a child
What is the general nature of your reason for seeking therapy?
Primary Insurance Type
BCBS Centennial Care
Molina Centennial Care
New Mexico Health Connections
Presbyterian Centennial Care
Tricare / MHN
True Health New Mexico
I'd like to pay out of pocket
I'd like to use my out of network benefits
I don't know my insurance information
Insurance ID #
Insurance Group #
Which providers are you most interested in seeing? (visit
to read about our counselors)
First Provider With Opening
Unsure, please help me decide.
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.)
12 - 4 p.m.
4 - 6:30 p.m. (evening appointments frequently have a waitlist)
Weekends (not currently offered, but check box if interested)
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
Please confirm each of the following policies of Elevation Counseling
I am aware of the 24-hour cancellation policy for all sessions
I am financially responsible for any amounts not covered by my insurance, including co-pay or deductible
I am not seeking court-ordered therapy or therapy for child custody arrangement
How did you find Elevation Counseling?
A friend/family member who is a past or current client
Health insurance provider directory
Referral from another therapist
Referral from my physician
Albuquerque Public School
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.
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