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Appointment Request

Request an Appointment with Elite Psychology and Wellness

To request an appointment, please fill out the form below:

Please note the form below is not for therapy or emergency services

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Client Date of Birth(Required)

Guardian Name if Patient is under 18 years old

What type of counseling are you seeking?(Required)

Tell us more about what is bringing you in for counseling(Required)

Type of Insurance(Required)

Do you know a therapist you would like to work with?(Required)

Policy Holder Name(Required)

Policy Holder DOB(Required)

Member ID(Required)

Optional: Upload front and back of your insurance card(Required)

Drop files here or

Max. file size: 32 MB, Max. files: 2.

Session Availability(Required)

Reason for Counseling(Required)

How did you hear about us?(Required)

Please tell us who we can thank for this referral?(Required)

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By providing your phone number, you agree to receive text messages from Elite Psychology and Wellness. Message and data rates may apply. Message frequency varies. Reply STOP to opt out or HELP if you need more information.