Schedule With Us

Thank you for your interest in working with us. Please complete the form below to request a free consultation or be added to our waitlist if we are currently full.

After completing this form, we will contact you within 48 business hours with the steps to schedule your consultation or your waitlist status.

I would like... *

to schedule a 15-minute virtual (telehealth) consultation (and possibly added to the waitlist)

to be added to the waitlist

to be added to the waitlist AND also receive referrals for clinicians who have openings within the next two weeks

to NOT be added to the waitlist and instead be given referrals for clinicians who are available in the next two weeks

Acknowledgement of Financial Responsibility

Thank you for contacting us! We look forward to working with you.

Due to the high volume of referrals, and the wide range of plans available, we are unable to provide insurance benefits verification for prospective clients.

Please review the guide to insurance benefits included with the email to this form. It is also linked below for your convenience.

We recommend that you contact Member Services and confirm the details of your coverage using the provided list of questions (it will take approximately 5-10 minutes once you reach a live representative on the phone). Benefits summaries and in-network status of providers is also generally available through your insurance company’s subscriber portal, although this is less detailed.

Note that on occasion, insurers provide incorrect information. If you have a question regarding the accuracy of your coverage description, please contact us and we will do our best to address your concern.

Please download this form for benefits and financial information, including specific questions to ask your insurance regarding your coverage.

Insurance Benefits Verification Information

I have reviewed the Benefits and Payment Guide *

I have reviewed the Benefits and Payment Guide

I have verified my benefits by *

I have used my benefits previously for therapy

Contacting Member Services listed on my insurance card

Gathering information from the website portal for my plan

I did not verify my benefits coverage

Consultation Request and Waitlist Agreement

I affirm that I am NOT currently experiencing

- a mental health emergency

- suicidal ideation/plan/intent

- urges to harm myself or someone else.

I also affirm that if that changes at any point while I am on the waitlist, I will reach out to 911, my doctor, or my local or national crisis line.

I affirm that I am NOT currently experiencing *

I am not experiencing a mental health emergency at this time.

I am experiencing a mental health emergency at this time. Please give me information on how to access immediate support.

Emergency Resources

911
Western NC Mobile Crisis - 1-888-573-1006
988 - National Suicide Hotline
National Maternal Mental Health Hotline - 1-833-943-5746

Please also contact your Primary Care Physician or your OB, if applicable.

I understand that by my currently experiencing a mental health emergency, I am not able to be on the waitlist at this time, and that I will reach out to one or more of the above options. *

Yes

Waitlist and Contact Preferences

Please remove me from the waitlist on this date:

How did you find out about our practice? *

Preferred Method of Contact

Contact Info

This information will only be stored by Mindful Counseling PLLC. Any referrals that you consent to receive will come from us via email and you will be responsible for reaching out to the referrals you are given.

Our emails are encrypted in transit and stored securely on our servers. We cannot ensure that emails sent are stored securely on your devices or in your email accounts. If you would like, we can require a portal pickup of your email (you will log into Luxsci to retrieve your email) upon request. If you prefer to be contacted by phone, please leave your phone number in place of your email address.

Full Name *

Email *

Please be sure to use a personal, confidential email address and not a work email address that others (IT dept, a secretary, etc.) could have access to. We require an email address on file to provide telehealth links for your consultation or future telehealth appointments.

Phone *

Please be sure to use a personal, confidential phone number and not a work number that others (coworkers, a secretary, etc.) could have access to. * Note that we will not leave voicemails that do not have a personalized, identifying greeting.

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Preferences for Therapy

Please know that if you selected to receive referrals, a confidential version of the below answers will be shared with a therapist Facebook group providing services in your area. Again, your name and contact info will NOT be shared.

Please Select Your Provider Preference *

Preferred session frequency: *

Weekly

Every Other Week

Preferred way to meet: *

In Person

Virtual

Final Details

How are you planning to pay for therapy? *

Self-pay (Individual 60-minute session - $150)

Aetna and affiliated plans

Ambetter

BlueCross BlueShield and affiliated plans

United Health and affiliated plans

My Employee Assistance Program (Lyra, BHS, Carebridge, Wellspring, etc.)

Please give a brief description of what you hope to work on in therapy. *

If you are wanting referrals, do you have any preferences we should keep in mind? *