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Last Name
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How did you find us?
Google Search
My Insurance Company
PsychologyToday
My Pastor or Church
Linked In
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Whom Are You Seeking Counseling For
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Would your like first availability or work with a specific clinician?
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First Availability
Geneva Gonzalez
Fran Singson
Ariel Birkholz
Grace Talbott
Sarah Cordova
Ben Hickman
Holly Steverson
Megan Ortiz (Waitlist)
Josh Freeman (Waitlist)
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How would you like to receive services?
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In-Person Only
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Briefly describe the issue you would like to work on.
Insurance Information (Optional)
Who is your insurance carrier for mental/behavioral health?
n/a - I plan to be private pay
Aetna Commercial Plan
Aetna EAP
Aetna Medicaid
Anthem Commercial Plan
Anthem EAP
Anthem FEP
Anthem Medicaid Plan
Carelon Behavioral Health Commercial
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Optum EAP
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Sentara Medicaid
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United Health Care EAP
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Member ID
Date of birth (required to verify insurance)
Insurance Card Front/Back (Optional)
Insurance Card Front/Back
Late Cancellation and No-Show Fee Policy
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I understand that a working credit, debit or HSA card is required to be kept on file in order to hold my appointment. I understand if I fail to provide more than 24 hour notice of cancellation, I will be charged the full amount of the current private-pay rate as insurance passes this cost on to the patient.
Email Risk Acknowledgement and Use Consent
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I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Counsel RVA therapists and/or office staff communicating with me via email or text message
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