First Name *

Last Name *

Date of birth *

Phone *

Email *

Address *

Postal code *

Whom are you seeking counseling for *

How would you like to receive services? *

In-Person Only

Telehealth Only

Open to Both

Briefly describe the issue you would like to work on. *

Would you like first availability or work with a specific clinician? *

Insurance Verification (If you plan to utilize your insurance)

*Some therapists (but not all) are in network with BCBS, United, & Aetna. We can also help you use out-of-network benefits.

Date of Birth of Client

Name of Insurance

Insurance ID

Front of Insurance Card (Picture)

Back of Insurance Card (Picture)

Important Insurance Notice

Please note that not all of our clinicians accept insurance, and not all insurances are accepted. If your clinician is out-of-network, you may still be able to use your out-of-network (OON) benefits. We recommend using Thrizer, a service that can help you navigate and maximize your OON benefits, making the reimbursement process easier.

What's the Best Way to Contact You?

Would you like to receive our monthly newsletter with updates and our best mental health tips?

Yes

How did you hear about us? *

Email 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 ATX Mental Health therapists and/or office staff communicating with me via email or text message