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STILL WATERS COUNSELING

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Request Counseling Today

We do not accept Medicaid plans or Medicare plans. However, we are able to accept Medicare Advantage through UHC and Aetna plans. If you need financial assistance, please visit Everyone's Healing for information on how you can receive financial assistance.

Counseling Request Form

Request a counselor today

First name*

Last name*

Email*

Phone*

Birthday*

Month

Day

Year

Will you be using insurance or private pay?*

Insurance

Cash Pay

If using insurance, please select your provider. If using cash, please select N/A.*

Blue Cross Blue Shield PPO

Aetna

Cigna

UMR

UHC

Tricare

Healthlink

N/A

What days are you available to attend sessions? (Select all that apply)*

Monday

Tuesday

Wednesday

Thursday

Friday

Other

What times are you available to attend sessions? (Select all that apply)*

Morning

Afternoon

Evening

Other

In person or telehealth? Please note in person is only available in Springfield, IL.*

In person

Telehealth

Open to either

Type of counseling (select all the apply)*

Individual

Couple's

Play Therapy/Therapy for my child

EMDR

Accelerated Resolution Therapy (ART)

Family Counseling

Cognitive Behavioral Therapy (CBT)

Internal Family Systems (IFS)

Dialectical Behavior Therapy (DBT)

Other

If seeking children's therapy please list the name and age of your child.

If seeking couples therapy please list the name, phone number, and email of your partner.

I would like to address the following: (select all that apply)*

Grief/Loss

Trauma

Anxiety

Depression

Substance Use

Sexual Trauma

Relationship Issues

Workplace Stress

Parental/Post Partum Stress

LGBTQ+ Issues

Gender Identity

Anger/Emotional Regulation

Burnout/Overwhelm

Self Esteem

Major Life Changes

Discrimination/Oppression

Other

Please provide additional information for seeking counseling. *

Is there anything else you would like us to know to help connect you with an appropriate therapist?*

Are you willing to be placed on a waitlist?*

Yes

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