Submit a request – MySpectrum Counseling & Coaching

Please choose your issue below

Your email address

Name of Individual(s) Who Will See Therapist

Name of person completing form or answering questions (if different from patient)(optional)

What is your relationship to the patient

Phone number for best contact

Please note that by providing your phone number, you are consenting to an occasional text message notification from MySpectrum LLC pertaining to scheduling or services. You may revoke this consent at any time by replying to text messages with "STOP".

Date of Birth (For Each Participant In Therapy)

State

Please provide which state the patient will primarily be in during sessions. Sessions are teletherapy by default. In-person sessions can only be provided at our North Chesterfield, VA location and are dependent on availability.

City

Select "Other (write-in)" if your city and state are not listed.

Write-in city and state(optional)

Are you a first responder or the spouse or child of a first responder?(optional)

Check this box if you are getting free sessions through an EAP. EAP stands for employee assistance program, which is through your workplace.(optional)

Name of your EAP (ie- ComPsych, Cigna, Anthem, etc.,)

EAP Disclosure

A referral from your EAP to a specific clinician does not guarantee you will be scheduled with that therapist. EAP companies are not regularly aware of our therapist availability and occasionally provide guidance that is contradictory to our practice's scheduling process. Our schedulers will review your inquiry and check our available clinicians' expertise to confirm we have providers who meet your needs. If you wish to inquire about the availability of a specific clinician, please include that at the end of this form.

EAP Name

Other EAP Name(optional)

If you do not know the EAP name, please write your employer's name or the name of the service you believe is paying for sessions.

Curalinc Case Number

Insurance Provider of Prospective Client

Tricare vs Veteran Affairs

If you have been referred to us by the Department of Veterans Affairs and they are covering your sessions, please go back and select "Optum Community Care through Veteran Affairs" instead of Tricare. Selecting Tricare when your coverage is through the VA will limit service options.

Some Virginia Premier policies are administered by Kaiser Permenante. If this is the case for your policy, please contact your insurance to secure a single-case-agreement before sessions. Otherwise, you may be responsible for out-of-network costs.

Please contact your insurance to secure a single-case-agreement before sessions. Otherwise, you may be responsible for out-of-network costs.

Write-in the name of your insurance provider if not listed in the drop-down above.

Do you have a secondary insurance or dual policy?(optional)

Secondary Insurance Provider of Prospective Client

Write-in the name of your secondary insurance provider if not listed in the drop-down above.

Check this box to acknowledge:

If you are using an insurance policy, you are responsible for knowing what mental health coverage that policy provides. If you want to know the cost of your sessions through insurance prior to scheduling or adding payment information to your chart, please contact the number on the back of your insurance card and ask them about your outpatient therapy benefits.

Check this box if this is a referral from Chesterfield CSA/FAPT(optional)

Please provide your Hanover CSA/FAPT Case Manager's first name

Please provide your Hanover CSA/FAPT Case Manager's last name

Please provide your Hanover CSA/FAPT Case Manager's contact information(optional)

Check this box if this is a referral from Hanover CSA/FAPT(optional)

Please provide your Hanover CSA/FAPT Case Manager's first name

Please provide your Hanover CSA/FAPT Case Manager's last name

Please provide your Hanover CSA/FAPT Case Manager's contact information(optional)

How did you hear about MySpectrum? (required)

QMHP Name(optional)

QMHP Email(optional)

Please add additional information for how you heard about MySpectrum here(optional)

Other:

Check this box if you are currently seeking services in relation to a current or upcoming court case(optional)

Please describe the court case(optional)

Check this box if the patient is currently in foster care(optional)

Please attach the foster agreement at the bottom of this form submission. If you do not have the foster agreement, include the contact information for the foster care coordinator here:(optional)

Please describe what is bringing you to therapy today. (PLEASE NOTE - MySpectrum Counseling and Coaching does not provide diagnostic testing and does not provide medication management without a referral from a MySpectrum therapist.)

Partner's Email Address

For couples counseling, both individuals will receive correspondence from our office.

If applicable, select up to 3 additional things you'd like to address with your therapist.(optional)

Disability Leave / FMLA Disclosure

While some MySpectrum clinicians are able to complete disability leave or FMLA paperwork for patients, scheduling with one does not guarantee that they will fulfill this request. Please disclose whether you will require temporary/disability leave paperwork before scheduling by listing it in the presenting issues. The timeline and decision for completing this kind of paperwork will depend on the progress and outtakes of regular therapy sessions. Please check this box to acknowledge this information.

Are you seeking EMDR Therapy?(optional)

EMDR Disclosure

If you are seeking EMDR services, then the clinician(s) available to provide that service will have to review your intake packet and determine that you are eligible before scheduling. This means that we may not be able to schedule you for EMDR services even if a certified therapist is available. Please keep this in mind as you proceed with our intake process.

Scheduling Constraints(optional)

All of our therapists work different schedules. If you have any inflexible time constraints, please list them above. Fewer time constraints can lead to faster scheduling, so please only note those limitations that don't have room to change.

Please provide us with any other information that would be helpful as we match you with a therapist(optional)

Description

Please enter the details of your request. A member of our support staff will respond as soon as possible.

URL(optional)

Attachments(optional)

Add file or drop files here