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!
* Required
Client's First Name
*
Your answer
Client's Last Name
*
Your answer
Client's Date of Birth
*
MM
/
DD
/
YYYY
Cell Phone Number
*
Your answer
What type of counseling are you seeking?
*
Individual therapy for an adult
Individual therapy for a child
Couples counseling
Family Therapy
What is the general nature of your reason for seeking therapy?
*
Your answer
Email Address
*
Your answer
Primary Insurance Type
*
Choose
BCBS Centennial Care
BCBS Commercial
GEHA
Magellan Commercial
Molina Marketplace
New Mexico Health Connections
Presbyterian Centennial Care
Presbyterian Commercial
Tricare
True Health New Mexico
UMR
United HealthCare Commercial
Western Sky Community Plan
ChampVA
Christus Health
Aetna (we are out-of network)
Cigna (we are out of network)
I don't know my insurance information
Other
Insurance ID Number or Medicaid#
*
Your answer
Insurance Group #
*
Your answer
Have you ever been hospitalized for a mental health, substance abuse or alcohol condition?
*
Yes
No
Other:
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).
*
Yes
No
Other:
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).
*
First Provider With Opening
Unsure, please help me decide
Telehealth
LGBTQ+ affirming
Christian-focused counselor
Non-religious therapy
Leatrice Allen (adults, couples, families)
Robin Bartee (teens, adults, telehealth)
Maureen Brickley (children, teens, adults)
Linda Dodds (adults, couples)
Laura Heitman (children 12+)
Porter Holiday (preteens, teens, adults, families)
Trish Korenchen (adults, couples)
Rhonda Madsen (teens 13+, adults)
Amy McGhee (children, teens, adults)
Helen McKinney (adults)
Deborah Moore (adults, couples)
Michelle Morgan (teens, adults, couples)
Rigena Nordyke, PhD (preteens, teens)
Nance Pease (teens, adults, couples)
Chad Pfeiffer (teens 12+, adults)
Brian Reeves ( couples, teens 12+, adults, families)
Lorene Ryan (children, teens, adults)
Ruth Schoder (children, teens, adults, couples, families)
Valerie Seibert (children, teens, adults, families)
Claire Siwula (adults)
Adele Somma (adults)
Jonathan Wilks (children 12+, teens, adults, families)
Other:
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.)
*
Monday
Tuesday
Wednesday
Thursday
Friday
8-11 a.m.
12 - 4 p.m.
5 - 7 p.m. (evening appts have a longer wait-list)
I'm flexible!
Weekends (not currently offered, but check box if interested)
Other:
Required
If your preferred times and/or therapists are full would you like to be placed on a wait list?
*
Yes
No
Other:
How may we contact you for scheduling? (check all methods that you are willing to receive).
*
Phone call
Email
Text
Required
Please confirm each of the following policies of Elevation Counseling
*
I am aware of the 24-hour cancellation policy for all sessions ($55 charged for late cancellation or no-shows)
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 or divorce proceedings
I am not seeking assessment for disability or SSA benefits (we can provide suggested referrals)
Required
How did you hear about Elevation Counseling?
*
Psychology Today
Google search
A friend/family member who is a past or current client
Health insurance provider directory
Word of mouth
Referral from another therapist
Referral from my physician
Facebook
Albuquerque Public School
Other:
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.
Submit
Never submit passwords through Google Forms.
This form was created inside of Elevation Counseling.
Report Abuse
Forms
