top of page


New Client Appointment Request

State of residence. (Please note that you should be in your state of residence for your scheduled appointments.)

Date of Birth - DOB

Month
Day
Year

By providing your phone number, you agree to receive text messages from Reflections Counseling & Coaching regarding appointments, benefits, and scheduling. Your information will remain private and will never be shared with third parties, except as required by law or with your explicit consent.

By providing your email address, you agree to receive communication from Reflections Counseling & Coaching regarding appointments, benefits, and scheduling. Your information is kept confidential and will never be shared with third parties, except as required by law or with your explicit consent.

Please share a bit about what brings you here so we can connect you with the provider best suited to your needs

We accept most major insurance plans. If you plan to use insurance, please list your carrier below so we can verify your benefits and confirm any out-of-pocket costs.

If you are not using insurance, our self-pay rate is $150 per session. In this case, please write ‘N/A’ in all insurance fields.

If you don’t have your member ID available, please enter ‘Unknown.’ Additional details may be requested to complete benefit verification.

If available, please upload a copy of the FRONT of your insurance card to help us verify your benefits more quickly.


Accepted files: PDF, JPG, PNG, DOC (max 15 MB each, 50 MB total). If your file is too large, or you feel that there is an error, please email it to trish@reflectionscounselingcoaching.com

If available, please upload a copy of the BACK of your insurance card to help us verify your benefits more quickly.


Accepted files: PDF, JPG, PNG, DOC (max 15 MB each, 50 MB total). If your file is too large, or you feel that there is an error, please email it to trish@reflectionscounselingcoaching.com

Requested Services: (Select all that apply)
How would you like to meet with your therapist? (Select all that apply)
Choose a therapist:
How did you hear about us?
bottom of page