Thanks so much for filling out this appointment request form! It helps us answer any questions you might have before scheduling, and then helps us to match you with the best therapist for your needs, preference, and schedule.

First Name *

Last Name *

Phone *

Email *

City *

State *

Date of birth (pick year first) *

Select which type of counseling you are interested in, we don't provide couples counseling, only Premarital Counseling: *

Individual Counseling Age 18+

Premarital Counseling

Both

How would you like to receive services? *

In-Person Only

Telehealth Only

Open to Both

Briefly describe the issue(s) you would like to work on. *

What Insurance would you like to use? (we are unable to bill Medicare or Medicaid) Scroll Down to Find Your Insurance *

Insurance Member ID (if you would like us to check what your will be paying for therapy)

Please list several days and times (M-Fri) that work for you for appointments: *

How did you hear about us or find us? (scroll down for options) *

Is there anything else that would be helpful for us to know? (like therapist preference)

Would you like to opt in to receive mental health & relationship tips periodically sent to your email? *

Yes

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 Bozeman Counseling Center therapists and/or office staff communicating with me via email or text message while I am setting up my initial appointment. After I am established as a client, Bozeman Counseling Center will invite me to Spruce Health for secure messaging.

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