Appointment Request

Client's First Name *

Client's Last Name *

Client's Date of Birth *

If you are seeking counseling for someone other than yourself, what is your name and relationship to the client?

Email *

Phone *

What's your preferred method of contact? *

Phone

Both

Who are you seeking counseling services for? *

Myself

My child

My adolescent

Me and my partner/spouse

My family

Briefly describe what you want to work on in counseling. This helps us determine which of our therapists would be a good fit for you. *

What day(s) do you prefer to have your appointment? *

Monday

Tuesday

Wednesday

Thursday

Friday

What time of day works best for your appointment? *

My schedule is flexible.

9AM - 11AM

12PM - 3PM

4PM - 7PM

How Would You Like To Receive Services *

In-Person Only

Telehealth Only

Open to Both

How do you plan to pay for counseling services? (Please note we are not in-network with Medicare, Medicaid, Anthem HIP, nor CareSource HIP): *

Pay out-of-pocket
Use my out-of-network benefits
EAP (Anthem, Beacon, IU, or Optum)
Anthem Blue Cross & Blue Shield
CareSource Marketplace
IU Health
Tricare (Certified OON)
UMR
Unified Group Services
United Healthcare
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If you plan to use insurance for counseling services, please provide the following information so we may verify your benefits.

Insurance Member ID:

Upload image of the front of your insurance card

Relationship of client to policy holder:

Self
Child
Spouse
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Does the client have secondary insurance coverage?

How did you hear about us? *

Email and SMS Text Message Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Life Enrichment Counseling therapists and/or office staff communicating with me via email or text message.

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