Welcome to Envision Counseling! We’re here to help you find your positive vision and bring it to life. Please fill out the form below so we can learn more about you.
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 office, social worker, physician, etc.)
Referred by insurance carrier
Referred by a friend or colleague
Online search (Google, Bing, etc.)
Social media (Facebook, TikTok, etc.)
ZocDoc
Other
Are you new to Envision Counseling?
*
Yes
No
Please enter your therapist's name
Please tell us your reason for requesting counseling services:
*
Would you like remote or in-person counseling?
*
I prefer the convenience of teletherapy (video sessions)
I prefer in-person sessions, but would be willing to try teletherapy
I prefer in-person sessions
I’m not sure
What are your preferred appointment times? Select all that apply
Mornings
Afternoons
Evenings
Weekends
How do you intend to pay?
*
Self-pay
Insurance
Who is your insurance carrier?
Aetna
Anthem BCBS
CareFirst
Cigna
Kaiser
Optum EAP
Sentara
United Healthcare
Envision is unable to accept Medicaid or Medicare insurance.
Please upload a copy of the front of your insurance card.
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Please upload a copy of the back of your insurance card.
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