Self-Scheduling | Replaced on 7/14/25

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To get started:

Please answer the following questions to schedule your first appointment. This should take no more than 5 minutes.
All the following questions pertain to the patient's information.
Please have your insurance card available to complete the scheduling process. If you do not have insurance and would like to learn about other options, please call us at 877-759-5017.

Important note:

Your first appointment will be held virtually, however, we will need to collect additional information from you before we can see you.

*This appointment may be canceled or changed if we cannot reach you within 1 business day of booking your visit.

All information is held in the strictest confidence. At no point is information disclosed or shared without a patient's written consent.

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gclid

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Referrer

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utm_source

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Lead Source

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Get State Code

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Market

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Method of Contact

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Get Page URL

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utm_medium

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utm_campaign

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Are you currently or have you ever been an Eleanor Health member?* This field is required.

YESNO

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Were You Referred By Another Medical Provider?* This field is required.

YESNO

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Name of the Referring Provider Organization

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Are you 18 or older?* This field is required.

YESNO

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Privacy Policy* This field is required.By providing this information you have read and agreed to our Privacy Policy.

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To get started, let's make sure we provide services in your state. Where do you live?* This field is required.

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Do you currently have medical insurance?* This field is required.

YESNO

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Who is your current insurance provider?* This field is required.Choose from this list of insurance providers in Massachusetts

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Are you 21 or older?* This field is required.

YESNO

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Thank you for considering Eleanor Health. We are committed to supporting you on your journey. You must be 21 years or older to receive care from Eleanor Health if you have MBHP as your insurance.

While you may not be eligible for our services at this time, we’re here to help you find the support you need. Here are some additional resources that are available to you:

SAMHSA’s National Helpline: Call 1-800-662-HELP (4357)

Suicide & Crisis Lifeline: Call 988 or 800-273-8255

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Who is your current insurance provider?* This field is required.Choose from this list of insurance providers in Louisiana

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Who is your current insurance provider?* This field is required.Choose from this list of insurance providers in New Jersey

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Who is your current insurance provider?Choose from the list of insurance providers in New Mexico

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Who is your current insurance provider?* This field is required.Choose from this list of insurance providers in North Carolina

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Who is your current insurance provider?* This field is required.Choose from this list of insurance providers in Ohio

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Who is your current insurance provider?* This field is required.Choose from this list of insurance providers in Washington

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Who is your current insurance provider?* This field is required.Choose from this list of insurance providers in Texas

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Who is your current insurance provider?* This field is required.Choose from this list of insurance providers in Florida

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Who is your current insurance provider* This field is required.Choose from the list of providers in Idaho

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Who is your current insurance provider* This field is required.Choose from the list of providers in Pennsylvania

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Full Name* This field is required.

First Name

Last Name

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Date of Birth* This field is required.

Date

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Cell Phone Number* This field is required.

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Home Phone NumberOptional

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Receive SMS Communications?Would you like to receive SMS communications from Eleanor Health

Yes

No

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E-mail* This field is required.

example@example.com

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Legal Sex* This field is required.

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Thank you for considering Eleanor Health. We are committed to supporting you on your journey. If you don't see your insurance listed, we may still be able to help. To verify if Eleanor Health is in-network with your insurance plan, or to see if you qualify for our self-pay program, fill out this form and someone from our team will reach out to you or give us a call at 877-759-5017.

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Thank you for considering Eleanor Health. We are committed to supporting you on your journey. We now offer self-pay options to those who qualify. For more information on our self-pay program, please visit our self-pay page or call us at 877-759-5017 to chat with our team.

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Thank you for considering Eleanor Health. We are committed to supporting you on your journey. Unfortunately we do not currently serve members in your location. If you would like to be notified once we start serving members in your area, please fill out this form and we will reach out to you when treatment is available.

While you may not be eligible for our services at this time, we’re here to help you find the support you need. Here are some additional resources that are available to you:

SAMHSA’s National Helpline: Call 1-800-662-HELP (4357)

Suicide & Crisis Lifeline: Call 988 or 800-273-8255

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Thank you for considering Eleanor Health. We are committed to supporting you on your journey. You must be 18 years or older to receive care from Eleanor Health.

While you may not be eligible for our services at this time, we’re here to help you find the support you need. Here are some additional resources that are available to you:

SAMHSA’s National Helpline: Call 1-800-662-HELP (4357)

Suicide & Crisis Lifeline: Call 988 or 800-273-8255

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We’re sorry, we are unable to schedule current Eleanor Health community members online at this time. Please reach out to us at 1-877-759-5017 to schedule an appointment.

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You're almost there!

By clicking "submit" you confirm this information is accurate and you will be redirected to start scheduling your first appointment.

If you have any questions, please call (877) 759-5017 and our team will be standing by to assist you.

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Insurance Name for capture in Lead

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StateId

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InsuranceId

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How text consent is obtained?