• Hicks Counseling Services
    Beverly Hicks, M.Ed.
    NC: LCMHC, CCS, CADC
    TX: LMFT, LCDC2301

    Mailing: 9650 Strickland Rd. Suite 103-424
    Raleigh, NC 27615

    Office: 919.904.4257
    Fax: 866.594.1848
    www.hickscounseling.com

     

  • Hicks Counseling Services, PLLC.

    Beverly Hicks, M.Ed.NC: LCMHC, CCS, CADCTX: LMFT, LCDC
  • GENERAL INFORMATION FORM

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  • Primary Care

  • Primary Insurance Coverage

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  • **Please present your card to therapist to be photocopied or upload a picture here.

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  • Mental Heath Insurance Coverage If Applicable

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  • Assignment and Release

  • I, the undersigned certify that I (or my dependent) have insurance coverage stated above and assign payment directly to entity named above all insurance benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor/therapist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance. I am entitled to a copy of this agreement by requesting one.

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