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Pre-Schedule Information Form

Step 1 of 4

25%
  • MM slash DD slash YYYY
  • If 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.
    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.
  • Let's get your insurance information

  • 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"
    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.
  • It is usually the longest number you have on your insurance card. For some insurances, it is still your social security number
  • This is usually the smaller of the numbers on your insurance card
  • MM slash DD slash YYYY
  • Typically this number is on the back of your insurance card. It may be called Provider Support, Customer Support, or Authorization Line
  • Common insurance types are: Blue Cross/Blue Shield, Medica, UHC, AETNA, CIGNA, HelathPartners, Ucare, SelectCare, PreferredOne.
  • It is usually the longest number you have on your insurance card. For some insurances, it is still your social security number
  • This is usually the smaller of the numbers on your insurance card
  • MM slash DD slash YYYY
  • Typically this number is on the back of your insurance card. It may be called Provider Support, Customer Support, or Authorization Line
  • Thanks, now tell me when you are available to come in.

    Saturday openings depend on clinician availability
  • Last Step!

  • When you are ready, go ahead and hit the submit button. A confirmation email will arrive shortly thereafter.

Contact Us

  • Phone:(763) 515-4563Opens in your application
  • Toll Free:(888) 863-6360Opens in your application
  • Email:questions@helpwithsolutions.comOpens in your application

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