New Client Form | Chugach Counseling & Consulting LLC

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New Client Form

Therapy Services
EMDR Consultation
Clinicians
Billing Portal
New Client Form

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

FYI: Julissa has immediate availability

Stacey, Miriam, Kelsie & Kathryn 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 *

In-Person only
Televideo only

Ubicacion *

Solo en persona
Solo video

In Person Clinican Preference *

Televideo Clinican Preference *

Televideo Terapeuta Preferencia *

I am seeking:

Couples/Family Therapy
Individual therapy

Julissa currently has the following openings for weekly individual sessions: *

thurs 8:45
thurs 10:15
thurs 11:30
Waitlist

Julissa is only in office Tuesdays - Thursday

Jen currently has the following openings for weekly sessions: *

Mondays 8:45
waitlist

Jen is only in office Mon-Thursday JEN ONLY WORKS WITH 18 AND OLDER

Kathryn currently has the following openings for weekly sessions: *

Mondays @ 12:45
Tues @ 10:15
waitlist

Kathryn is only in office Mon, Tuesday & Thursday

miriam currently has the following openings for weekly sessions: *

Tues @ 9am
waitlist

Julissa actualmente tiene las siguientes vacantes para sesiones semanales: *

jueves 8:45
jueves 10:15
jueves 11:30
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 *

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

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