Counseling Within Reach, PLLC Appointment Request Form

Counseling Within Reach, PLLC Appointment Request Form
**Emergency assistance and Crisis Support are not available through this form.**

If this is an emergency, please call 911.

For 24/7 crisis support, reach out to the number below:

National Suicide Prevention Lifeline: 1-800-273-8255
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Phone Number

Area Code Phone Number
Insurance Provider (if applicable)
Policy Holder

First Name Last Name
Insurance ID #
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Requested Services

You can select more than one service.
Services

Free, 15 minute Consult Telehealth Counseling
Please express your reason for requesting the service(s)
Please list your availability for appointments. Days of the week and times.
Should be Empty: