Request Appointment | Center for Resilience Strategies

Appointment Request

Please complete the request form below. We will contact you to discuss therapist options and appointment availability as soon as possible.

"*" indicates required fields

1Personal Information

2Payment Information

3Therapy Needs

Name*

Email*

Phone

Date of Birth*

Preferred Communication*

Preferred Language*

How did you hear about us?*

Do you personally know any of our therapists, and/or is a member of your family/friend group currently seeing a CRS therapist? (If yes, please provide their name)

In which state are you located?*

Colorado

Pennsylvania

Are you using insurance benefits, or paying out of pocket?*

PLEASE NOTE: If you have out-of-network insurance but are interested in paying out of pocket, please select “Out-of-pocket” from the choices below.

Are you using insurance benefits, or paying out of pocket?*

PLEASE NOTE: If you have out-of-network insurance but are interested in paying out of pocket, please select “Out-of-pocket” from the choices below.

Policyholder Legal Name

Please type n/a if the policyholder is one seeking therapy.

Policyholder Date of Birth

Address*

Street Address City State ZIP Code

Are you covered under Health First Colorado (Colorado Medicaid)?*

If you would like to use insurance benefits, please provide Member ID# and Legal Name.

If you would like to use EAP (Employee Assistance Program) benefits, provide authorization information.

If interested in our income-based sliding scale, what is your estimated annual income?

For Individual Therapy, enter income amount for self. For Couples or Family Therapy, enter household income amount.

Why type of support are you seeking?

Individual Therapy

Individual Therapy for Child or Teen

Couples Therapy

Family Therapy

Ketamine-Assisted Psychotherapy (KAP) **Adults only

KAP is available in PA and MN

What location are you interested in visiting?*

Colorado Virtual Therapist Preference