WaitList - 1 Identity Counseling

Request Appointment | WaitList

Thank you for requesting an appointment. Complete the form below to provide information needed to confirm we are in-network with your insurance.

You will initially be added to our waitlist.
Our admin, will confirm that we are in-network and that no prior authorizations are required.
When all insurance information is confirmed, you will receive a link via email from the SimplePractice portal to complete all intake forms.
Once you have completed the forms, you will be able to select an appointment available on Jenelle’s calendar.
You will receive a confirmation once your appointment request has been approved.

We look forward to meeting you!

Therapy Options(Required)

I live in either IN, MI, or IL

I am looking for In-Person Sessions

I am looking for TeleHealth Sessions

I'm available for both In-Person/TeleHealth

What type of request is this?(Required)

Adult | Individual Counseling

Minor | Grades 7-12 with an ACEs score of 4 or higher

Your Information

Your Name(Required)

First Last

Sex(Required)

Male

Female

Date of Birth(Required)

Email(Required)

Phone(Required)

Legal Address of Client(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Availability Notification Preference(Required)

Email

Text

To help maintain your privacy and confidentiality, please use a personal email address.

Reason for Counseling(Required)

Select all that apply

Anxiety

Control Issues

Depression

No Purpose in Life

Life Adjustment

EMDR

Trauma/cPTSD/PTSD

Developmental Wounds

Other

Describe 'Other' (optional)

See link at top of the page to determine ACEs score.

Minor's Legal Name — Complete only if this is a request for a minor grades 7-12.

First Last

Grades 7-12 includes current or next school year (if name is added to the waitlist during the summer months).

Minor's Email

The email identifies the client in SimplePractice and must be different than the parent/guardian email.

Minor's Date of Birth

Please complete the insurance information below. We will use this information to confirm that we are in network with your Insurance Payer.

I have either Anthem, BCBS, Cigna, UnitedHealthcare, Optum, BeaconHealth, Marketplace, Medicare, or a form of Indiana Medicaid insurance.(Required)

Yes

No

Medicaid only available to Indiana residents.

Policy Holder - Primary Insurance(Required)

Self

Spouse

Parent

Other

Insurance Payer:(Required)

Insurance Member ID(Required)

Please upload an image of the FRONT of your insurance card.(Required)

Accepted file types: jpg, jpeg, png, gif.

Please upload an image of the BACK of your insurance card.(Required)

Accepted file types: jpg, jpeg, png, gif.

Policy Holder Name (If different from Client)

First Last

Legal First and Last Name

Policy Holder Phone (If different from Client)

Policy Holder Address (If different from Client)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Policy Holder Sex (If different from Client)

Male

Female

Policy Holder Date of Birth (If different from Client)