Psychotherapy Client Wait List
Please fill out our HIPAA compliant wait list form. Our Support Team can contact you when we have openings. Please be advised that we may have a 4-5 week wait period for BCBS members seeking psychotherapy services.
Name of Person Completing the Form
*
First Name
Last Name
Name of Prospective Client
*
First Name
Last Name
Date of Birth or Prospective Client
*
-
Month
-
Day
Year
Date of Birth of Person who is seeking services
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Service Requested
*
Adult Psychotherapy
Child Psychotherapy
Marriage & Couples
Assessment & Evaluation
Insurance
*
BCBS
Aetna
United Health Plans/UHC
UMR
Horizon Blue Cross Blue Shield
Other
Briefly Describe why you are seeking therapy services
*
Ex: work-related anxiety, relationship issues, parent/child conflict
History
Have you every previously received mental health services, psychotherapy services, etc.?
*
Yes
No
Have you ever been hospitalized for psychiatric issues?
*
Yes
No
If yes, please explain and provide the dates.
Have you ever had or are you currently experiencing thoughts of suicide?
*
Yes
No
If yes, please explain and provide the dates.
General Information
Are you currently taking prescription medication?
*
Yes
No
If yes, please list all medications.
In a few sentences, please describe why you are seeking therapy services at this time.
*
How did you hear about us?
*
Search Engine
Insurance Company
Word of Mouth
Doctor Referral
Other
Upload Front of Insurance Card
Browse Files
Cancel
of
Upload Back of Insurance Card
Browse Files
Cancel
of
Submit
Should be Empty: