Online Services & Appointment Request

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Note: If you are experiencing an emergency, please dial 911 to contact local emergency response personnel or 211 if you are a resident of La Crosse County, Wisconsin for the crisis line.

Please be assured that this online appointment request is a secured and confidential area and that information entered and submitted is confidential.

You may also contact us by phone through our Appointment Information Desk at 608-785-7000 x221.

Fields marked with an * are required fields; your request cannot be processed unless these fields are completed.

Attention: If you are not the intended client (person receiving services), please be sure to fill this form out with the appropriate client information.

CLIENT INFORMATION
Client First Name: *
Client Middle Initial:
Client Last Name: *
Client Former Name: (if applicable)
Client Gender: *	MaleFemale
Client Birthdate: *	MM/DD/YYYY
Client Address: *
Client City: *
Client County: *
Client State: *	2 character abbreviation
Client Zip Code: *
Client Email:
Client Primary Phone Number: *	HomeWorkCell     (xxx) xxx-xxxx
Client Secondary Phone Number:	HomeWorkCell     (xxx) xxx-xxxx
Client Fax Number:	(xxx) xxx-xxxx
Please tell us the best time to contact you and which number to call:
INSURANCE BILLING INFORMATION
Insurance Plan and Name:	Tell us what insurance plan you are covered by. Please remember to bring your insurance card to your appointment. Note: If you are unsure which numbers or information to provide us about your insurance plan or are unsure if you plan covers certain services, please call us at 608-785-7000 x21.

Use Client Information from above
Insurance ID Number:
Insurance Policy Holder: *	SelfSpouseOther
Insurance Policy Holder Birthdate: *	MM/DD/YYYY
Name of Requesting Individual: *
Person Responsible for Bill: *
Primary Phone Number: *	HomeWorkCell     (xxx) xxx-xxxx
Secondary Phone Number:	HomeWorkCell     (xxx) xxx-xxxx
Fax Number:	(xxx) xxx-xxxx
Address: *
City: *
State: *	2 character abbreviation
Zip Code: *

DESCRIBE REASON FOR APPOINTMENT
Parent/Guardian Name (If client is a minor or requiring guardian):
Current Symptoms: *
When did symptoms begin or how long has current problem been present: *
Primary Treatment Requested: *	IndividualCouplesFamily
Secondary Treatment Requested:	IndividualCouplesFamily
Previously Seen at Stein Counseling:	NoYes

Seen by Whom:
Seen when:
Is this the return of a previous problem or something new: *

Current Medication:
Gender Preference of Counselor: *	First AvailableMaleFemale
Preferred Provider's Name (if applicable):
Preferred Meeting Day and Time: *	First AvailableAnyMondayTuesdayWednesdayThursdayFriday  at  First Available
Secondary Preferred Meeting Day and Time: *	First AvailableAnyMondayTuesdayWednesdayThursdayFriday  at  First Available
Additional Information:	You will be contacted within one business day of your submission to review additional outpatient counseling and financial information, including insurance coverage, before an appointment is offered. If you would like to provide additional information to the appointment office staff, please type it here:
To help us keep automated scripts from completing this form please answer this question: What is 1 + 1?: *