MCS Counseling Center | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

To help us verify your benefits, please enter your member ID, the name of your insurance company, and the name and date of birth of the person who carries the policy (the primary insured—this may be you, a spouse, or a parent). This information ensures we can confirm eligibility before scheduling.

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

EAP Provider

Are you planning to use EAP benefits? If yes, please provide the name of your EAP, if known. EAP-covered sessions are provided at no cost to you; however, we require a payment method on file for applicable late cancellation or missed appointment fees.

EAP Case or Authorization Number

Enter the case number or authorization number you were given by your EAP. If we need your authorization letter for verification, we’ll send you a secure message through your client portal. If you are not using EAP services, please leave this blank.

Client Preferences

Preferred clinician

Select a clinician from the list

How are you comfortable meeting?

Choose any formats that work for you. We’ll use this to help connect you with the right clinician.

Is there anything you’d like our scheduler or your assigned therapist to be aware of?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

If you’re joining our waitlist, we’ll add you to the list for the provider you prefer. When that provider has availability, you’ll receive an email with a link to complete your intake forms. Questions? You can reach us anytime at admin@mcsjax.com or 904-701-4662.

Please confirm you understand the waitlist process.

Yes, I understand I have questions, please contact me

Waitlist Provider Request (Optional)

If the clinician you were hoping to see was not listed in the Preferred Clinician dropdown, it means they are currently on a waitlist and not accepting new clients. If you would like to request a specific clinician who is on a waitlist, please indicate their name below.

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.