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

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

Phone Number*

Area CodePhone Number

YesNo

How did you hear about us?

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

Yes (please complete plan information below)No, Cash Pay is preferred

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

Associate Therapist, under supervision- Starting at $85Licensed Therapist $120 (only available for virtual appointments)Student Therapist, under supervision - Starting at $50

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.

No one, I need a therapistOther

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.

Telehealth is preferredIn-Person at the West Sacramento - 3960 Industrial Blvd West Sac., #600 CA 95691In-Person at the Folsom - 530 Plaza Drive, Suite 130 Folsom, CA 95630In-Person at the Roseville Office - 2270 Douglas Blvd #112 Roseville, CA 95661

For myselfAs a coupleBoth (individual and couples therapy)Minor child

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

Date*

Date

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

Signature*