New Client Form | Chugach Counseling & Consulting LLC

Therapy Services
EMDR Consultation
Clinicians
NEW CLIENT FORM
Employment

Therapy Services
EMDR Consultation
Clinicians
NEW CLIENT FORM
Employment

Have more questions or ready to get started?

We offer free 30-minute consults for therapy

We are unable to bill Medicaid/Medicare

In-network with Blue Cross, United/UMR, Tricare West, TriWest, Multiplan

Call your insurance provider directly to ask about your specific co-pay amount.

The CPT codes used for billing: 90791 For Intake; 90837 For Individual therapy; 90847 For Family Therapy

TELEVIDEO only openings at this time. You can fill out the form below to reserve your spot

All of our in-person clincians are full.

English o Español *

English
Español

Name *

First

Last

Nombre *

First

Last

Client's pronouns/pronombres de clientes *

Client's Date of Birth/Fecha de nacimiento del cliente *

I understand Chugach does not take on clients younger than age 16 //Entiendo que Chugach no acepta clientes menores de 16 años.

Phone Number *

May we text this number? *

Yes
No

Número de teléfono *

¿Podemos enviar mensajes de texto a este número? *

Si
No

Location *

Televideo only

Ubicacion *

Solo video
En Persona

Open session times ( please pick preference) *

Monday @ 9
Monday @ 11
Monday @1
Monday @ 2:30
Monday @ 4
Tuesday @ 9
Tuesdays @ 10:30
Tuesday @ 2:30
Tuesday @ 4
Wednesday @ 9
Wednesday @ 11
Wednesday @ 11:45
Wednesday @ 1
Wednesday @ 2:30
Wednesday @ 4
Thursday @ 9
Thursday @ 11
Thursday @ 1
Thursday @ 2:30
Thursday @ 4

I am seeking: *

Individual therapy

Julissa actualmente tiene las siguientes vacantes para sesiones semanales: *

lista de espera

Julissa sólo está en la oficina de martes - jueves.

My availablity for sessions *

Be as specific as possible with what days and times of the day work

Mi disponibilidad para sesiones *

Sea lo más específico posible con qué días y horas del día funcionan

Email: DO NOT USE A WORK EMAIL *

personal emails only no work please!

PRIMARY Insurance Provider *

WE ARE ONLY ABLE TO BILL THE INSURANCES LISTED ABOVE

Please let us know your specific tricare plan ( Prime, Select, Active duty, Reserve, Retired, Young adult ) *

Secondary Insurance *

WE ARE ONLY ABLE TO BILL THE INSURANCES LISTED ABOVE

Proveedor de Seguro PRIMARIO *

SÓLO PODEMOS FACTURAR A LOS SEGUROS LISTADOS ARRIBA.

Seguro secundario *

SÓLO PODEMOS FACTURAR A LOS SEGUROS LISTADOS ARRIBA.

What would you like to focus on in therapy? Please state a few goals you have for yourself *

¿En qué te gustaría enfocarte en la terapia? *

Who is this for? *

¿Para quién es esto? *

We also encourage going to emdria.org & clicking find a therapist to find other EMDR therapists in Alaska.

Find us here

Chugach Counseling & Consulting, LLC
11901 Business Blvd. Suite 203 Eagle River, AK 99577
907-202-7166
855-936-3236
Admin@ChugachCounseling.com

© 2026 · Chugach Counseling & Consulting ·

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