Round Rock Counseling Services

Round Rock Counseling Services Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

Clients Address

Billing & Payment

Payment method

How do you plan to pay for your sessions?

If using insurance, please select from the following:

Aetna BCBS Cigna Healthcare Highways Medicare Moda Sendero Tricare TriWest Healthcare Alliance UHC/Optum Other

Insurance card upload

Upload a photo of your insurance card

Insurance ID/Member Number

Please enter your member ID number shown on your insurance card. TRICARE members, please enter your DoD or benefits number

Insurance Group Number

Please enter your group number shown on your insurance card

Subscriber's name

The subscriber is the individual who owns the insurance policy. Sometimes this is the client, and other times it may be a parent, spouse, or other family member.

Subscriber's date of birth

Please enter the DOB of the subscriber (if not you!)

Client Preferences

What is your availability?

Please provide the days and times that work best for you (please be specific)

Limited to 600 characters

Preferred Session Modality

Would you prefer your sessions to be held in person at the office or online via telehealth

In-person only Telehealth only No Preference

Preferred Counselor

Is there a particular counselor you're interested in working with?

Jessica Warren, MA, LPC Rebecca Sato, MA, LPC Deborah Coan, MA, LPC Erin Davenport, MA, LPC-Associate Evie Carmody, MA, LPC-Associate No Preference

Prefered method of contact

How do you prefer we contact you?

Phone call Text message Email No preference

Frequency of sessions

Would you like your sessions to be weekly or every other week (bi-weekly)

Weekly Every other week (bi-weekly) No Preference

Reason for care

What will be your main focus of therapy

Please provide a description of what brings you to seek therapy at this time. This can be as brief or as detailed as you like. All answers are kept confidential.

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.