Pre-Schedule Information Form "*" indicates required fields Step 1 of 4 25% Where would you like to be seen?St. Michael/AlbertvilleAnnandaleOnline preferredPatient/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*What Type of Appointment Reminder Would You Like* Email Messages Text Messages No Reminders, Please We use an automated text message system that, by default, will alert you one day in advance of your appointment based on what you check here. By checking the text messages box, you acknowledge that Solutions Counseling can send you text messages on their behalf. Review our privacy policy and/or terms and conditions at https://helpwithsolutions.com/terms-of-service/. Msg & Data Rates apply. Msg Frequency may vary. For any text messages received, text HELP for more info or reply STOP to opt out.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 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 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)? 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 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 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 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 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?* I was a past client Friend or family member Saw your sign Insurance company Medical doctor Psychiatrist Google/Yahoo/Bing search Therapist/Psychologist Google ad County referred Email Psychology Today School District Other Other Medical Doctor Name (optional)Psychiatrist Name (optional)OtherIf 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.
