Center for Wellness Encounters

Consultation Request

Please answer a few brief questions so we can determine whether your needs are a good fit for our practice. Submitting this form does not establish a therapist-client relationship or guarantee a consultation appointment.

Full name

Email address

State where you will be located for therapy

What is your current therapy status?

This will be my first time in therapy I have been in therapy before and am returning I am currently in therapy

What are you hoping to receive from therapy with us that is different from or in addition to your current therapy?

Are you planning to end your current individual therapy if you begin working with us?

Yes No I’m not sure yet

What type of therapy are you seeking?

Individual therapy Couples therapy Family therapy

Is the main concern you want help with primarily about a marriage or partner relationship?

Yes No

Relationship-focused concerns may be better addressed in couples therapy.

You may still submit this request. We will review what you share and determine whether individual therapy, couples therapy, or another referral is the most appropriate next step.

What are you hoping therapy will help you with?

Please keep this brief. You do not need to provide your full history here.

How do you plan to pay for therapy?

What insurance company and plan do you have?

Center for Wellness Encounters only accepts PPO insurance plans. If you plan to use insurance, please enter the name of your insurance company and plan. Insurance coverage will be confirmed before services begin.

What EAP program are you using?

Next step: Your request will be reviewed for clinical and scheduling fit. If a consultation is appropriate, you will receive an email with a link to schedule it and instructions on what to expect.

I understand that this form is for consultation screening only and is not for emergencies, crisis care, or time-sensitive clinical concerns.

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Do not use this form for emergencies. If you are experiencing an emergency, call 911 or go to the nearest emergency department.