Forms

Registration Forms

Please print and fully complete ALL of these registration forms and bring them with you to your first session. Having completed forms ready will allow you or your family member to begin your/their first session on time.

Benefits Verification Assistant

If you plan to use insurance benefits to help you pay for your counseling this form MUST be completed 36 hours before your appointment. You must make an appointment with a therapist first.
Patient's name: *
Date of Birth: (mm/dd/yyyy) *
Insurance Subscriber's Name: *
Ins. Subscriber's Birthdate: (mm/dd/yyyy) *
Social Security Number
Telephone No: *
Email address *
Postal Address *
Name of counselor you scheduled with *
date & time of first appointment: (mm/dd) *
Insurance Company *
Ins. Customer Service Tel: (usually on back of your card) *
Ins. Mental Health Tel: *
Ins. I D No. *
Ins. Group No. *
Medical Group if HMO *

Important Note:

Please complete the above form as accurately as possible. This will assist us in verifying your Insurance Benefit information. If you can email or fax a copy of your insurance card (front and back), that would be very helpful. Use the form below titled Benefits Verification Assistant. It is most important that you call your insurance company yourself to confirm what your benefits are specifically. A quote of benefits from your insurance company is never a guarantee of payment.

Insurance Benefits Forms

Insurance Card Submission

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