Contact Information of Individual Completing this form:

First Name *

Last Name *

Age *

Street Address *

City *

State *

Zip Code *

Phone Number *

(###) ###-####

Email Address

Who are you considering a tele-health video counseling appointment for? *

Myself
My Child/Dependent
My Partner and I

Who will be considered as the primary client? *

Myself
My Partner

Partner's First Name *

Partner's Last Name *

Partners Age *

Child's First Name *

Child's Last Name *

Child’s Age *

Does the child live in the home with you? *

Child’s Street Address *

Child’s City *

Child’s State *

Child’s Zip Code *

Is there an Additional Guardian for the Child? *

Guardian's First Name *

Guardian's Last Name *

Guardian's Age *

Guardian’s Phone *

(###) ###-####

Guardian's Email Address

Does the Additional Guardian live in the same home as the child? *

Additional Guardian's Street Address *

Guardian's City *

State *

Zip Code *

What is the primary reason you are currently seeking counseling? *

What is the primary reason you and your partner are seeking counseling? *

What is the primary reason you are seeking counseling for your child? *

What type of insurance coverage are you planning for services? *

Primary Insurance
Secondary Insurance
Employee Assistance Program
Self Pay

(Select All That Apply)

Please list the Insurance Company Name(s) & ID/Policy # from the card(s): *

IMPORTANT INSURANCE UPDATES:
Dorian Angebrandt, LCSW and Choices in Counseling, LLC are not currently able to accept new referrals from CareSource for services. We apologize for any inconvenience that this may cause. Please contact the office at (317) 346-6252 with any questions and/or concerns you may have at this time re: these current insurance limitations.

Where should the link for enrollment and appointment remiders be sent? *

Text Message
Email
DO NOT Send Link by Text or Email

(Choose One)

Where should the link for enrollment and appointment remiders be sent? *

(Choose One)

Where should the link for enrollment and appointment remiders be sent? *

Text Message
Email
DO NOT Send Link by Text or Email

(Choose One)

Where should the link for enrollment and appointment remiders be sent? *

(Choose One)

TEXT CONSENT: For the purpose of coordinating scheduling, reminding client’s of upcoming appointments and appointment status(s), enrollment, and general communication throughout counseling services with Dorian Angebrandt, LCSW (dba Choices in Counseling, LLC) selecting “TEXT" or “EMAIL" above constitutes consent to receiving scheduling, reminders, appointment status information, and all other confidential and direct communication by Text or Email between Dorian Angebrandt, LCSW (dba Choices in Counseling, LLC) and the individual(s) who(s) contact information is provided above.

By Typing YES in the box below, I understand and approve to be contacted according to the TEXT CONSENT statement above: *

Type YES in the box above to consent.

Thank you for completing an appointment request form for
Dorian Angebrandt, LCSW & Choices in Counseling, LLC

Your request will be reviewed as soon as possible.

Alert!