Pre-Schedule Information Form Step 1 of 4 25% Patient/Client LEGAL Name* First Last Person Completing Form* First Last Relationship to the Client*I am the clientSpouse/PartnerMother/FatherStepparentGuardianOtherClient Date of Birth* Date Format: MM slash DD slash YYYY Client Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Email* Best Phone Number*The Responsible Party is the name of the person who is legally responsible for the client and payment of services that are not covered by insurance.Responsible Party Name* First Last Responsible Party Address Same as Client Address Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What Type of Reminder Would You Like*Email MessagesText MessagesNo Reminders, PleaseWe do not do phone reminders; we use an automated system that, by default, will alert you one day in advance of your appointment based on what you check here.Will You Be Using Insurance?*Yes, I'll be using insurance.No, I won't be using insurance.Check Your Approval* I understand that phone calls and messages may be left on the best phone number and/or email you provide. What location would you prefer to be seen at?*St. Michael/AlbertvilleGratia Counseling/Andover Let's get your insurance informationType of InsuranceCommon insurance types are: Blue Cross/Blue Shield, Medica, UHC, AETNA, CIGNA, HelathPartners, Ucare, SelectCare, PreferredOne. If you wish to use the CounselingCare program, simply type in "CounselingCare"Is this an Employee Assistance Plan (EAP)?NoYesI don't know for sureAn EAP is different than your regular insurance as it often cover the full cost of your time with a therapist. Sometimes people refer to these as "free sessions." Often times, UBH/Medica policies have EAP sessions available. Check with your insurance company or employer for more details.ID NumberIt is usually the longest number you have on your insurance card. For some insurances, it is still your social security number Group/Account NumberThis is usually the smaller of the numbers on your insurance card Policyholder Name First Last Policyholder Date of Birth Date Format: MM slash DD slash YYYY Policyholder Relationship to CientI am the clientSpouse/PartnerMother/FatherStepparentGuardianOtherInsurance Phone NumberTypically this number is on the back of your insurance card. It may be called Provider Support, Customer Support, or Authorization LineDo you have secondary insurance?*YesNoSecondary Type of InsuranceCommon insurance types are: Blue Cross/Blue Shield, Medica, UHC, AETNA, CIGNA, HelathPartners, Ucare, SelectCare, PreferredOne.Secondary ID NumberIt is usually the longest number you have on your insurance card. For some insurances, it is still your social security number Secondary Group/Account NumberThis is usually the smaller of the numbers on your insurance card Secondary Policyholder Name First Last Secondary Policyholder Date of Birth Date Format: MM slash DD slash YYYY Secondary Insurance Phone NumberTypically this number is on the back of your insurance card. It may be called Provider Support, Customer Support, or Authorization LineSecondary Policyholder Relationship to CientI am the clientSpouse/PartnerMother/FatherStepparentGuardianOther Thanks, now tell me when you are available to come in.Monday Morning Afternoon Evening Tuesday Morning Afternoon Evening Wednesday Morning Afternoon Evening Thursday Morning Afternoon Evening Friday Morning Afternoon Evening Saturday Morning Afternoon Evening Saturday openings depend on clinician availability Anything else we need to know about your availability? Last Step!How did you hear about us?*Bing SearchI clicked on your Google AdFacebook AdReferred by a past/current clientPsychology TodayI'd prefer notInsurance companyMedical DoctorNetwork TherapyI searched GoogleReferred by school districtTherapist/Psychologist/PsychiatristYahoo SearchInsurance CompanyThe PatchOtherOtherIf there is anything else we should know at this time, feel free to include it in the box below.When you are ready, go ahead and hit the submit button. A confirmation email will arrive shortly thereafter.UntitledFirst ChoiceSecond ChoiceThird Choice
