Request for Services — Linked Therapy

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Linked Therapy

Mental Health Counseling

Community Education & Training

Anger Management Program

Parent Education Program

Patient Information

Payment, Billing & Insurance

Request Services

General Inquiries

Linked Therapy

Mental Health Counseling

Community Education & Training

Anger Management Program

Parent Education Program

Patient Information

Payment, Billing & Insurance

Request Services

General Inquiries

Folder: Services

Mental Health Counseling

Community Education & Training

Anger Management Program

Parent Education Program

Folder: Patient Information

Payment, Billing & Insurance

Folder: Contact Us

Request Services

General Inquiries

Client Type *

Adult

Minor ( Linked Therapy is not accepting new minor clients at this time.)

Couple ( Linked Therapy is not accepting new clients for couples’ sessions at this time.)

Client Legal Name *

First Name

Last Name

Email Address *

This will be used for scheduling.

Client Phone Number *

Client Birth Date

MM

DD

YYYY

State

Indiana

Illinois

Arizona

Other

Name of Insurance *

Self-Pay- No Insurance

Open Path

Aetna

Anthem Blue Cross and Blue Shield

Caresource

Cigna

MDwise

Medicaid

MHS (Managed Health Services)

United Healthcare

Other

Preferred Day *

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Any Day

Preferred Time *

Morning 8:00am-12:00pm

Afternoon 12:00pm-5:00pm

Evening 5:00pm-8:00pm

AnyTime

Reason for Request

Thank you for reaching out to us. Your request for services has been received. Our team will review your information and contact you at the email address provided. We're excited to embark on this journey with you and provide the support you need.

If you have any additional questions or concerns, please feel free to reach out to us via email at scheduling@linkedtherapy.com.

Request for Services