Reflections Counseling and Coaching New Client Appointment Request

🌿Welcome to Reflections Counseling & Coaching! We’re grateful for the opportunity to support you.

To help us get started, please complete the information below. Our team will review your details, verify any benefits, and provide next steps within 24 hours. If you are a current or returning client, you do not need to complete this form again—please contact us directly at trish@reflectionscounselingcoaching.com or call us at 678-807-9379. Thank you for trusting us with your care. 🌿

Please note: This form only needs to be completed once. If you have already scheduled an appointment and are looking for intake paperwork, you’ll find it in our client portal. You should have received an email invitation to access your forms.

Client’s First and Last Name (exactly as shown on the insurance card) If you’re completing this form on behalf of someone else, please provide your own information in the next section.

Last name

Your Name and relationship to Client (if different from Client's name)

Today's Date

Month

Day

Year

Time

HoursMinutes

Address

Client's primary state of residence. Please note that you should be in your state of residence for your scheduled appointments.

Client's Zip Code

Phone

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.

Email address

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.

Insurance Carrier

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.

Member/Subscriber ID

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

Birthday

Month

Day

Year

For couples or family counseling, please list the name(s) of your partner and/or participating family members.

For couples or family counseling, please provide the email address of each participant age 13 and older.

If this is an EAP referral, please provide the EAP name, authorization number, number of approved sessions, and effective dates.

Upload Insurance Card

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

Back

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

What can we be helpful with?

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