Request Services - New Mexico Crisis Counseling

Request Services

Whether you’re in crisis, feeling overwhelmed, or simply looking for experienced support, we’re here to help.

We provide secure telehealth counseling for clients throughout New Mexico.

Please complete the form below and one of our admissions staff will contact you within 48 business hours to discuss next steps.

Request For Services

FIRST NAME(Required)

LAST NAME(Required)

AGE(Required)

DOB(Required)

MM slash DD slash YYYY

SSN (optional)

PHONE(Required)

EMAIL(Required)

REASON FOR REQUEST (check all that apply)(Required)

I have recently experienced a mental health crisis or attempted suicide.

I am on a waiting list for long-term therapy and need crisis support.

I am currently in therapy but could benefit from a short course of crisis-specific treatment, suicide-specific treatment, interim counseling, skills training, or resiliency coaching.

I was recently discharged from inpatient care or long-term therapy and need crisis support.

I am impacted by a major life transition or traumatic event.

I have been impacted by the suicide of someone close to me.

Other

Please explain other reason for the request:

DO YOU HAVE MEDICAID?(Required)

YES

MEDICAID NUMBER

CENTENNIAL HEALTHCARE NUMBER

RECERTIFICATION DATE

DO YOU HAVE MEDICARE?(Required)

YES

MEDICARE NUMBER

DATE COVERAGE STARTS

PRIVATE INSURANCE(Required)

Blue Cross & Blue Shield

Presbyterian Health Plan

United Healthcare

None Of The Above

ARE YOU AN ACTIVE-DUTY SERVICE MEMBER, VETERAN, OR A MILITARY FAMILY MEMBER?(Required)

YES

ADDITIONAL NOTES (OPTIONAL)

ARE YOU CURRENTLY IN ACUTE CRISIS OR IN DANGER OF DOING HARM TO YOURSELF OR ANYONE ELSE?(Required)

YES

We provide interim counseling, coaching, and skills training. If this is an acute suicidal crisis and you need to speak to someone immediately, please contact 988 Suicide Hotline, the New Mexico Crisis Line, or 911 Emergency Services.

Do you consent to being contacted by New Mexico Crisis Counseling?(Required)

YES

Preferred method of contact:(Required)

Phone

Confirmation Of Understanding

This request for services is part of an automated system that is not monitored around the clock. Your request will required up to 48 business hours to process. If this is an acute suicidal crisis and you need to speak to someone immediately, please contact 988 Suicide Hotline, the New Mexico Crisis Line, or 911 Emergency Services.

Confirmation(Required)

I understand.