Intake Consultation Form Kelley Smith Counseling LLC1115 Bethel Rd.Columbus, OH 43220(614) 706-0704kelleysmithcounseling@gmail.com Name * First Name Last Name Phone * (###) ### #### Email * I'm interested in... * EMDR therapy iRest Yoga Nidra Meditation Safe and Sound Protocol (SSP) Life System Biofeedback Traditional Talk Therapy Additional Message (Optional) My preferred days and times for counseling are: * I would like: * In Person Telehealth Insurance preference * Medical Mutual Anthem Aetna Oscar Health Oxford Cigna/Evernorth Optum Behavioral Health: UHC/UMR/UBH/Surest CareSource Medicaid CareSource Marketplace Self Pay Birthdate (double check for accuracy) * Required for access to scheduling portal MM DD YYYY Referral Source: * Thank you! I am looking forward to meeting you. I will reach out to connect with you on scheduling within 24 hours of this submission. If you feel that you are in crisis, please seek help at your nearest Emergency Room or call 911.
