Appointment Request Form

To request a session, please complete the following form.

First Name *

Last Name *

Phone *

Email *

For Whom Are You Seeking Counseling *

How did you find us? *

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

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.

What's the Best Way to Contact You?

Insurance Information (Optional)

Who is your insurance carrier for mental/behavioral health?

Member ID

Date of birth (required to verify insurance)

Insurance Card Front/Back (Optional)

Insurance Card Front/Back

Late Cancellation and No-Show Fee Policy *

I understand that a working credit, debit or HSA card is required to be kept on file in order to hold my appointment. I understand if I fail to provide more than 24 hour notice of cancellation, I will be charged the full amount of the current private-pay rate as insurance passes this cost on to the patient.

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 Counsel RVA therapists and/or office staff communicating with me via email or text message

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