Iowa Family Counseling LLC Send Message

Who would be receiving care?

Your info

For insurance verification
(Select all that apply)
Reason for care
What is happening or what is different? What stressors are you currently experiencing? What do you hope will be different by seeking help? What are your goals for counseling?
Limited to 600 characters
Please check all that apply:
If yes - diagnosis? Age of diagnosis and diagnosing provider?
Limited to 600 characters
If yes - medication name, dosage and prescriber? What OTC (over-the-counter) medications do you typically use (i.e. Tylenol, Zyrtec, etc)?
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Administrative
How did you hear about Iowa Family Counseling?
Billing & Payment
How do you plan to pay for your counseling services?
Upload a photo of your insurance card
Please list any additional (secondary, tertiary) insurance information that the client is covered under and the policy holder's information if different than the client.
Limited to 600 characters
Client Preferences
Select a clinician from the list
Where would you like to be seen for counseling sessions?
Any needs or preferences that will help us be successful in your treatment?
Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.