Round Rock Counseling Services Send Message

Who would be receiving care?

Your info

For insurance verification
What is the marital status of the minors parents
Billing & Payment
How do you plan to pay for your sessions?
Upload a photo of your insurance card
Please enter your member ID number shown on your insurance card. TRICARE members, please enter your DoD AND benefits number
Please enter your group number shown on your insurance card
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. For TRICARE members, it will be the name of the Sponsor.
Please enter the DOB of the subscriber (if not you!)
Beneficiary's Plan Type:
Client Preferences
Please provide the days and times that work best for you (please be specific)
Limited to 600 characters
Would you prefer your sessions to be held in person at the office or online via telehealth
Is there a particular counselor you're interested in working with?
How do you prefer we contact you?
Would you like your sessions to be weekly or every other week (bi-weekly)
Reason for care
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
Administrative
Is your (or your sponsors) initial enlistment before or after Jan. 1, 2018
Please select one of the following that applies to you

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.