Envision Counseling Individual Information Form
Email
*
example@example.com
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Non-binary/non-conforming
How did you hear about us?
*
Referred by professional (probation officer, social worker, physician, etc.)
Referred by insurance carrier
Referred by friend or colleague
Search engine (Google, Yahoo, etc.)
Social Media
Advertisement
Zocdoc
Other
Insurance Carrier (if applicable)
*
Aetna
Anthem BCBS
CareFirst
Cigna
Kaiser
United Healthcare
I do not intend to use insurance
Other
Is this a new service request
*
Yes
No - Please enter your therapist's name, or if you have a therapist in mind
When is your preferred meeting time?
*
Morning
Afternoon
Evening
Weekends
Would you prefer a male or female therapist?
*
Male
Female
No Preference
How do you feel about telehealth services (provided remotely via video)?
I prefer the convenience of telehealth services.
I would prefer in-person sessions, but I would be willing to try telehealth (at least for the initial assessment).
I want in-person sessions, and I would not like to be seen via telehealth at all.
I'm not sure, so I am flexible either way.
Please describe your reason for requesting counseling services
*
Please upload a copy of the front of your insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a copy of the back of your insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
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