Private contact request

Start the conversation.

Tell us how to reach you and when counseling could fit — that’s all we need for now. We typically respond within 1–2 business days.

How may we contact you?

Provide an email address, phone number, or both.

Who is this request for?

Myself Someone else

Your full name

Phone

Rivanna may contact me by (check all that apply)

Phone (no voicemail) Phone (okay to leave a voicemail) Text message Email

About the person seeking care

Requesting for someone else? Answer the rest of this form about them.

Where would care take place?

In-person care is in Charlottesville. Telehealth eligibility depends on location and provider.

Age group

Adult (18+) Adolescent (14–17)

What brings you here?

What would the person seeking care like to work on?

A brief description is enough. Please do not use this form for urgent or emergency concerns. 1,000 character limit.

Availability

Which days could they attend?

Select every day that could genuinely work, not just the day you’d prefer.

Which times could they attend?

Select every time range that could work on at least one selected day. We compare your answers with current openings — it’s possible no therapist has an opening during the times you select.

Mornings Afternoons Evenings Flexible on times

Payment

How will care be paid for?

Use insurance Private pay / self-pay

Rivanna Counseling is unable to accept Medicaid plans, including as private pay.

For some out-of-network plans, private pay with a superbill may be an option. Reimbursement is not guaranteed.

Communication consent