YMCA Employer Sponsored Appointment Request Form

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YMCA of the North Wellness Consult/Therapy Form

Ellie Mental Health and the YMCA of the North have partnered to provide you with mental health resources. As an employee of YMCA of the North, you can receive up to 4 therapy sessions or wellness consults free of charge.

Please indicate whether you want to schedule a Wellness Consultation or a therapy session:
Please indicate topics of interest for your Wellness Consultation or therapy session
I understand that I will be given up to 4 50-60 minute Wellness Consultations and/or therapy sessions from a practitioner at Ellie Mental Health as part of a wellness initiative offered by my employer.
I understand that my employer will not be notified that I (by name) have attended the Wellness Consultation/therapy session, and that the only information that will be provided to my employer is the number of employees who attend.
I understand that my employer will NOT be notified about any personal information shared during the Wellness Consultation/therapy session.
I understand that I will not be engaging in medically necessary or other therapeutic services and no part of the Wellness Consultation/therapy session will be considered treatment of any medical or mental health disorder.
I understand that if I decide that I might benefit from ongoing services (at my own cost, not paid for by my employer), Ellie Mental Health will help me identify what those services might be and make referrals for further support at my request.
I will not hold Ellie Mental Health liable for any outcomes that may result from engaging in a Wellness Consultation and if I have any questions regarding my Wellness Consultation I will talk to a member of the Ellie Mental Health team.
I understand that, if i pursue therapy sessions at Ellie Mental Health, additional forms and intake paperwork will be required for me to fill out.
I understand that the only documentation of the Wellness Consultation/therapy session will be this consent form (and any additional consent forms/intake paperwork required by Ellie Mental Health) and will be stored in a protected file at Ellie Mental Health, with access limited to the administrative & executive teams.