Appointment Request

Patient Full Name

Patient Date of Birth (MMDDYY)

Is the patient a minor? Is the patient a minor? Yes No

Home Address (Street, City, State, Zip)

Phone Number

Parent/Guardian Full Name

Is your home address and phone number the same as the patient? Is your home address and phone number the same as the patient? Yes No

Parent/Guardian Home Address

Parent/Guardian Phone Number

Email Address

Will you be self-pay or using insurance? Will you be self-pay or using insurance?Self-PayInsurance

Select state for coverage options Select state for coverage optionsMissouriVirginiaIllinoisFlorida - Self-pay only

Insurance Carrier Insurance CarrierMedicareMedicaidBlue Cross Blue ShieldAnthemCignaUnited Health CareHome State HealthAmbetterWellcareAetnaCenpaticoHealthy Blue

Insurance Carrier Insurance CarrierBlue Cross Blue ShieldCignaUnited Health CareAetnaOscar

Insurance Carrier Insurance CarrierBlue Cross Blue ShieldCigna

Who is the insurance holder? Who is the insurance holder? Myself Spouse Other parent/guardian

Full Name of Insurance Holder

What is the insurance holder's date of birth? (MMDDYY)

What service(s) are you interested in? What service(s) are you interested in? Therapy for myself Therapy for someone else Psychological Evaluation Emotional Support Animal Evaluation Emotional Support Animal Renewal Court Ordered Evaluation Group Therapy Legal Psychological Consult Custom Employee Wellness Program Clinical Supervision Sexual Offender Risk Evaluation

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