VIRTUAL COUNSELOR & COLLEGE TELEHEALTH
www.VirtualCounselor.com www.CollegeTelehealth.com 484.245.4455
PRIVATE PAY SESSION REQUEST
Welcome to Virtual Counselor & College Telehealth. Once you complete this form, please schedule with our Intake Coordinator who will match you with a clinician.
Due to their unique areas of speciality and demographic locations, our therapist rate ranges vary, which can be discussed during your intake call. We are not in-network with insurance and only accept private payment at this time. We are happy to provide you a super-bill for submission to your insurance company for OON reimbursement.
State Located
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List Current Location
Last Name
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Client Name
First Name
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Client Name
Email
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Phone number
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Referral Source
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Self referral
Minor under my care
I am make a referral for someone
How do you prefer to get started? :
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I am ready to schedule-Send me the initial forms
15min call with our Intake Coordinator
Date of Birth
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-
Month
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Day
Year
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What are the primary concerns that you are seeking services for?
Anxiety
Depression
Relationship Concerns
Anger
Traumatic Experience
Grief
Behavioral Concerns
Academic Stressors
Ongoing Mental Difficulties
COVID Related Stressors
Is there anything else you would like to share?
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Would you be interested in Spanish Telehealth services, if available?
No
Yes(Si)
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Client Portal & Intake Forms
Upon scheduling, you will be provided an email invitation to our online client portal. We request that you complete all intake documents 24 hrs prior to your initial session. During your intake session, your assigned clinician will review the forms in detail and answer any questions you may have.
Intake Forms
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I Understand and Agree.
24 Hour No Show Policy
If you would like to cancel a scheduled session, we kindly ask that you provide at least 24-hour notice.
No Show Policy
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I Understand and Agree.
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Referral Source Information
If you are making a referral on behalf of someone else, please complete this section.
Last Name
Parent or Referral Source
First Name
Parent or Referral Source
Email
Phone Number
Additional Information
Upload Additional Documents
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