Name *

First Name

Last Name

Phone *

(###)

###

####

Voicemail

Is it okay to leave a voicemail at this number?

Yes

No

How often do you anticipate attending therapy? *

Weekly

Twice weekly

Twice monthly

Monthly

Unsure/No preference/Other

What is your preferred method for therapy? *

In-person in Round Rock (all appointments are currently full)

Online

Unsure/No preference

How do you hope to pay for therapy? *

Ascend Counseling + Wellness accepts Aetna and Optum/United/Oscar insurance plans. For all other insurance plans, Ascend Counseling + Wellness is considered an out-of-network provider. A Superbill may be provided upon request for reimbursement from your health insurance plan. Please contact your plan provider to inquire about out-of-network benefits.

Private pay/out-of-pocket

Aetna insurance

Optum/United/Oscar insurance

Reimbursement for out-of-network benefits

I need a reduced fee.

Please indicate your scheduling preferences. Select all that apply.

Monica is available to meet with clients in person on Mondays, and virtually on Tuesdays, Wednesdays, and Thursdays.

Monday

Tuesday

Wednesday

Thursday

Morning (before noon)

Afternoon (noon-5 PM)

Evening (5 PM-6 PM)