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Hereba Mental Health Counseling, LMHC, PC.

124 Northern Lights Drive, Suite 30

North Syracuse, NY 13212

Phone: (315) 996-1980

Fax: (315) 996-1984

Check out some of our inspirations on social media!

Now offering online counseling

New Client Intake Form

First Name

Last Name

Phone

What are you seeking support related to? (please explain a bit about your concerns such as: depression, anxiety, stress, relationship issues, substance concerns, disordered eating, grief, etc.) This information is used to help match you with the best therapist for your needs.

Would you prefer telehealth or in person appointments? *

I prefer telehealth

I prefer in-person (and realize this may be a limited option)

I am open to both telehealth and in-person

What is your scheduling availability? (Please note we try to accommodate scheduling, however evening appointments can be limited) *

Daytime appointments, only

Evening appointments, only

Prefer evenings, but can be flexible

I can be flexible

Would you be willing to work with one of our gradute interns at a reduced rate? (If yes, more information will be emailed to you).

Yes

What type of insurance do you plan on using? *

Aetna

Cigna

Excellus BC/BS (Please answer question below regarding primary care doctor)

MVP

Optum (United Behavioral Health)

Out-of-network or for fee service

Other insurance not listed

Do you have a primary care doctor or psychiatrist that you've seen in the last year? *

Yes

No (If no, please understand if using Excellus insurance you need a primary care doctor and/or psychiatrist to help verify diagnosis - we can also help you with this!)

What is the name of your Primary Care Doctor? (if you don't have one, just type in N/A)

If using your insurance, what is your Insurance card's ID # (for benefits verification purposes)

If using insurance, what is your Date of Birth? (for benefits verification purposes).

Any other information we should know?

Thanks for submitting!

124 Northern Lights Drive, Suite 30

North Syracuse, NY 13212

Phone: (315) 996-1980

Fax: (315) 996-1984

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