New Client Interest Form

If you’re interested in starting therapy or want to check your insurance, please complete the form below.

Once received, we’ll send you an invitation to our Therapy Portal to complete your intake paperwork and provide information about your insurance coverage.

Questions? Email admin@horizoncounseling.org

Website:www.horizoncounseling.org

Name of Therapist you would like to work with. Provider availability varies. If your requested therapist is not available, Horizon will help match you with another clinician who fits your needs.

Other

Patient Information

Patient Name

First NameLast Name

Patient Date of Birth

Date

Parent/Guardian Name (if patient is a minor)

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If you don't answer, may we text you at the number above to schedule your appointment?

How did you hear about us?

We don't share your information with anyone, but like to see how clients hear about us. THANKS!

Do you wish to use insurance?

Primary: Plan name and Member ID and Add Insurance Card. Failure to add Insurance card will delay the intake/appointment process.

Please list plan name and member ID

Please add a photo of your insurance card FRONT OF CARD (Required for Insurance)

Browse Files

BACK OF CARD (Required for Insurance)

Browse Files

Secondary:Plan name and Member ID and Add Insurance Card. Failure to add Insurance card will delay the intake/appointment process.

Please list plan name and member ID

Please add a photo of your insurance card FRONT OF CARD (Required for Insurance)

Browse Files

BACK OF CARD (required for insurance)

Browse Files

Cash Pay Clients

Preferred language, besides English?

Could you please let us know your preferred gender for the therapist? We aim to accommodate your preferences to ensure your comfort and satisfaction. If you have any specific requirements or considerations, please feel free to share them.

Release to Verify Coverage

I certify that I (or my dependent) have insurance coverage with the identified agency/agencies, and assign directly to all benefits, if any, directly payable to Horizon Family and Community Services for services rendered. I understand that I am financially responsible for all charges whether or not paid by the insurance. I hereby authorize the clinical staff at Horizon Family and Community Services to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Which office would you prefer? Please Select all that apply:

Are you seeking therapy for yourself individually or as a couple?

Date

Items for us to know: Type of therapy you are seeking, days of week, time of day, (not required)

If "As a couple or Both" was selected, please provide partner's name, Birthdate, and email so we can create an account for them as well.

Name, Email, Birthdate

Phone Number

Area CodePhone Number

Signature