First Name

Last Name

Phone *

Email *

Please only provide a phone number and email address if it is safe for us to call, text, or email you. If it is not safe, please call us directly at (512) 387-4962 to get started.

Whom are you seeking counseling for

What type of services are you looking for?

Medication Management

Talk therapy

Ketamine Assisted Psychotherapy

Reiki

Preferred format for sessions

Would you like to utilize your insurance?

You are not required to disclose sensitive financial information until you are scheduled with a clinician. Providing insurance details now helps us verify coverage in advance.

Insurance ID

Legal Name of main policy holder

We need this in order to verify insurance

Date of Birth for Main Policy holder

We need this in order to verify insurance

Main Policy Holder Address

We need this in order to verify insurance

Please Upload the Front of Your Insurance Card

Please Upload the Back of Your Insurance Card

Consents

I consent to having Moonstone Counseling add my information to their Electronic Health Record

I understand Moonstone Counseling will send me a link to the client portal, and that it is my responsibility to complete the requested documents and consents.

I understand that Moonstone Counseling will attempt to verify insurance as a courtesy but cannot take responsibility if insurance payers provide inaccurate information.

Briefly describe the issue you would like to work with

Would you like first availability or work with a specific clinician? *

If the clinician you choose does not have availability, we will reach out with some additional options

What pronouns do you use?

Sharing is optional. We’ll use the pronouns you list when communicating with you.

What’s the best way to contact you?

Please note: we cannot share personal information via text and will need to email you for this

Would you like to sign up for our newsletter?

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.