New Client Appointment Request

Before you begin

We’re glad you’re considering ACR Counseling for support. Before submitting an appointment request, please take a moment to review the information below to help determine whether our services may be a good fit for your needs.

PRACTICE BOUNDARIES ACKNOWLEDGMENT

ACR Counseling provides scheduled outpatient mental health services through telehealth. Our clinicians are licensed to practice in specific states, and clients must be physically located in a state where their treating clinician is licensed at the time of each appointment. Please note that ACR Counseling is not a crisis or emergency service and does not provide 24/7 support, emergency intervention, forensic evaluations, or court-ordered treatment. Virtual outpatient therapy may not be appropriate for every individual or situation, and our team carefully considers whether we can safely and appropriately meet each prospective client's needs. Submitting an appointment request does not establish a therapist-client relationship or guarantee that services will be scheduled. Our team will review the information provided and may follow up to gather additional details, verify eligibility, or determine whether ACR Counseling is an appropriate fit for your care.

New Client Appointment Request Form

Please complete the information below so we can determine whether our practice is the right fit for your needs.

General Information

First name

Last name

Email address

Phone number

Birthdate

Month

Day

Year

State of residence

Are you interested in a free 15-minute consult or an intake session?

Consult

Intake

Not sure yet

Who are you completing this form for?

Myself

For a minor/dependent

For couple's therapy

Preferred days/times for sessions

Reason for seeking therapy

Insurance Information

Using insurance? Please upload a clear photo of the front and back of your insurance card. We'll use this information to verify your benefits and coverage.

Insurance provider

Front of insurance card

Please upload an image of the front of your insurance card.

Back of insurance card

Please upload an image of the back of your insurance card.

Preferred clinician

I acknowledge this form is not for emergency use and does not confirm clinical treatment.

What Happens Next?

Insurance Verification: Our administrative team will verify your benefits and coverage details.
Clinician Matching: We will review your clinical needs to ensure a good fit with your preferred or matched clinician.
Follow-up: You can typically expect a response via email or phone within 24-48 business hours to schedule your appointment.