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* MM slash DD slash YYYY Are you presently involved in family court?* Yes No Consent* I understand and agree to the Minor Policy requirementsIf you are scheduling for a minor child, each party with legal custody must agree to our Minor Policy prior to scheduling. By signing this policy, both parties agree not to use any part of therapy services for the purposes of a court case. This includes not requesting any records related to therapy services. Within the policy, both parties must explicitly agree not to conduct any depositions related to the provision of clinical services and/or calling the therapist to testify. Client Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What Type of Reminder Would You Like* Email Messages Text Messages No Reminders, Please We 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. Let's get your insurance informationType of Insurance Common 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)? No Yes I don't know for sure An 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 Number It is usually the longest number you have on your insurance card. For some insurances, it is still your social security number Group/Account Number This is usually the smaller of the numbers on your insurance card Policyholder Name First Last Policyholder Date of Birth 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?* Yes No Secondary Type of Insurance Common insurance types are: Blue Cross/Blue Shield, Medica, UHC, AETNA, CIGNA, HelathPartners, Ucare, SelectCare, PreferredOne.Secondary ID Number It is usually the longest number you have on your insurance card. For some insurances, it is still your social security number Secondary Group/Account Number This is usually the smaller of the numbers on your insurance card Secondary Policyholder Name First Last Secondary Policyholder Date of Birth 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 Search I clicked on your Google Ad Facebook Ad Referred by a past/current client Psychology Today I'd prefer not Insurance company Medical Doctor Network Therapy I searched Google Referred by school district Therapist/Psychologist/Psychiatrist Yahoo Search Insurance Company The Patch Other Other If 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.
