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.
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
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
New Mexico Health Connections
Presbyterian Centennial Care
True Health New Mexico
United HealthCare Commercial
Western Sky Community Plan
Aetna (we are out-of network)
Cigna (we are out of network)
I don't know my insurance information
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
to read about our counselors).
First Provider With Opening
Unsure, please help me decide
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)
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.
5 - 7 p.m. (evening appts have a longer wait-list)
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?
How may we contact you for scheduling? (check all methods that you are willing to receive).
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)
How did you hear about Elevation Counseling?
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
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 have long wait lists. You will receive a confirmation email and offers of available appointments from firstname.lastname@example.org. Please ADD our email to your contacts or check your SPAM folder if you haven't heard from us.
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This form was created inside of Elevation Counseling.