Appointment Request

Thank you for reaching out and expressing interest in scheduling an appointment. Your request is important to me, and I genuinely look forward to the opportunity to work with you. Demand for appointments is high, and I have a waitlist for new clients. Wait times vary, but I generally try to schedule new clients within 4-6 weeks.

PERSONAL INFORMATION

What are you seeking counseling for?

Short answer

First name

Last name

Birthday

Month

Day

Year

Email

I acknowledge that email may not always be secure, and give Remedy Counseling permission to contact through email.

Yes

No

Phone

Address

I give Remedy Counseling permission to text me at this number.

Yes

No

Preferred Method of Communication

Email

Text

Phone Call

Session Preference

Melanie offers both in-person and telehealth sessions. Please select the service you are primarily interested in (In-Person, Telehealth, or Hybrid). *** Please note that ALL clients will occasionally need to attend sessions via Telehealth.

Please Select Primary Preference:

In Office

Telehealth

Hybrid (In Office and Telehealth)

Please indicate which service you are seeking:

Weekly Sessions.

Intensive Sessions.

ADHD Evaluation.

PAYMENT INFORMATION

Session fees can be covered by paying out of pocket or using insurance benefits. Melanie is in-network with most, but not all, insurance plans.

It is a client's responsibility to understand your insurance plan's terms, benefits, and coverage. Please note that some services may not be covered by insurance.

I am not in-network with Medicaid or Medicare

I am not in-network with EAP (Employee Assistance Plans)

Payment Type

Insurance Provider

Insurance Member or Plan ID Number

Group Number (if applicable)

Insurance Card

Secondary Insurance (If applicable).

Please complete if a secondary insurance plan covers you.

If a secondary policy covers you, this information needs to be presented before your first appointment. I am not able to back-date secondary claims.

Secondary Insurance Provider

Secondary Insurance Member or Plan ID Number

Secondary Group Number (if applicable)

Current Office Hours

Monday 8:00 am-1:00 pm

Tuesday 8:00 am-5:00 pm

Wednesday 8:00 am-5:00 pm

Thursday 8:00 am-2:00 pm

Early morning and late afternoon appointments are in high demand and are rarely available for new clients. If you can accommodate a less-than-ideal appointment time, my policy is to prioritize established clients for high-demand slots as they open up. Please be aware that I cannot guarantee an appointment time that aligns with your ideal availability, but sharing this information will help me understand your needs better.

Appointment Availability

Any additional information about your availability you would like us to know?

Would you like to be added to my waitlist?

Yes.

No.

I would like to subscribe to your newsletter and mailing list.

Yes.

No.

Did someone recommend you to Melanie?

Thank you for taking the time to request an appointment. You will receive a response within two business days.