Contact Request Form • ECC

ECC

...personal growth and relationship strategies for individuals, couples, and families

Appointment Contact Request Form

Name

Date Of Birth

Your Gender

Preferred Pronouns

Phone

ZIP

Concerns

Were you referred by an Employee Assistance Program (EAP)?

What is the name of your EAP?

Prior Authorization Number

Which insurance would you be using if you went beyond your EAP sessions?

Insurance ID#

Do you have appointment scheduling preferences?

How would you prefer to be seen?

Do you prefer a male or female therapist

Preferred Therapist Request (If accepting new clients)

Please read and check the box that you understand

The therapists, clinicians and counselors affiliated with Edina Counseling Center (ECC) are not employees of ECC, they are independently licensed professionals. They practice under their own licenses and are solely responsible for the services they provide. While they may collaborate with ECC and its affiliated clinics, they maintain their autonomy in delivering care to clients/patients. Any opinions, recommendations, or actions taken by these professionals are their own and do not necessarily reflect those of ECC or its clinics. Clients and patients are encouraged to discuss any questions or concerns directly with their provider.

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