TalkCampus Counseling Request Form

Thank you for your interest in TalkCampus Counseling. This form is only visible to Associate Director of Student Services Lucyn Martindale. Please answer the questions below to the best of your ability to help determine how many sessions Longy can offer coverage for.

Student Information

Preferred Name

Last Name

Insurance Coverage

What insurance coverage do you have?

Does your insurance plan provide any mental health coverage?

Yes

I'm not sure

What mental health or emotional wellness coverage does your insurance provide?

Please refer to the details of your insurance plan to see if you may have coverage for mental health or emotional wellness services. Most insurance providers have a client website or portal where you can view your plan details. You will need to find this information before being able to proceed with this form.