Inner Light Mental Health Counseling, PLLC

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

I prefer you reach out via:

*Emails from the practice may occasionally be filtered into junk/spam folders, especially for first-time contact.*

Either email or phone Email (please check junk/spam folder if no response in 1-2 days) Phone call

Administrative

Inquiry reason (check all that apply):

I'm ready to schedule my first appointment I have questions about your approach or specialties I've had therapy before and want something different I have questions about fees, self-pay, or insurance I am a therapist inquiring about clinical supervision I'm not exactly sure what I'm looking for but would like to connect Other

If other, please explain:

Limited to 600 characters

What brings you to therapy at this time? Feel free to share as much or as little as you'd like:

Examples: overwhelm, stress responses, past experiences, relationships, feeling stuck

Limited to 600 characters

This practice does not provide emergency services. If you are in immediate danger or need urgent support, please use one of the resources below:

Call 988 (Mental Health Crisis Line), or text (Mental Health Crisis Support) HOME to 741741, or dial 911.

I confirm that I am not currently in immediate danger, including having active thoughts of harming myself or someone else, and I am safe to proceed with a non-emergency therapy prescreener at this time.

Billing & Payment

Are you planning to use insurance or private pay?

Do you have Medicare or Medicaid (including if it is your secondary insurance)?

At this time, we are unable to accept Medicare or Medicaid plans, even if they are your secondary insurance.

Yes No

Insurance card upload

Upload a photo of your insurance card

We use this information to verify eligibility and benefits, determine network participation, and obtain information about your mental health benefits. Uploading both sides helps us avoid delays in scheduling.

I authorize Inner Light Mental Health Counseling, PLLC to contact my insurance company to verify my eligibility and behavioral health benefits. I understand that benefit verification is not a guarantee of payment and that I remain financially responsible for any deductible, copayment, coinsurance, or non-covered services.

I agree

Is the insurance policy in your name?

Yes No

If no, please answer the following: 1-subscriber full legal name, 2- subscriber date of birth, and 3- your relationship to the subscriber:

Type n/a if the insurance policy is in your name.

Client Preferences

Preferred appointment days/times:

Example: Monday afternoons or Friday evenings would be best

Limited to 600 characters

Reason for care

What are you hoping will feel different as a result of therapy?

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.