Request for Services

Request for Services
We are ready to help you! We assess for mood/behavior issues and also for ADHD, Autism, and Learning Disorders, among other things.
- First, we need insurance information so we can help you understand your benefits.
- Then you can provide information to help us find a provider who can best help!
This is a secure, HIPAA compliant form. Your privacy and confidentiality is our priority.
How did you hear about us at BHC?
How did you hear about us at BHC?

Other
I am interested in starting this process with:
I am interested in starting this process with:

Other
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Client

First NameLast Name
Client's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearBirthdate
Client's Sex (as listed on insurance)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number. By providing a phone number you give us permission to call and leave a message.Format: (000) 000-0000.
Preferred Contact Email
example@example.com
Do you plan to use your insurance benefits to finance therapy, or are you seeking self-pay services?
Insurance Information
Please Upload a Copy of your Insurance Card (Front & Back)- optional

If you have a smart phone, you can take a picture of front and back and upload images from your phone, computer, or tablet.
Cancelof
Subscriber's Name

First NameLast Name
Insurance Carrier
Example: Blue Cross Blue Shield, Aspirus Health Plan, WEA Trust
Please choose your insurance plan from the following options:
ID #
Group #
Date of Birth of Insured Person

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Where Insured is Employed
Is there a secondary insurance plan?
Subscriber's Name

First NameLast Name
Insurance Carrier
Example: Blue Cross Blue Shield, Aspirus Health Plan, WEA Trust
ID #
Group #
Date of Birth of Insured Person

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Where Insured is Employed
Counseling Preferences
What is the client's age?
Client Age Range
What types of concerns does the client have? Check all that apply.

Other
Does the client (you, or your child) have difficulty with any of the following:

Other
If you chose Other, please feel free to give some limited information here as it helps us match you with a specialist in that area of difficulty.
Are you currently going through a divorce with contested custody?
Please note: Behavioral Health Clinic does not provide custody evaluations and its practitioners do not provide opinions about parental fitness or parent-child relationships with the court. While we are happy to support families, including children and their parent(s) who are going through stressful experiences such as divorce and legal proceedings, we are treating providers ONLY and we are not a good fit for any client who wishes their therapist to have contact with the court or its representatives. We treat the therapeutic relationship and the privacy and confidentiality of that relationship as the priority for all of our clients in pursuit of good mental health.

I can be available for appointments during these times (note: there may be limited availability for late aft./evening appointments. Choosing a number of possible days/times will increase our ability to serve you quickly & consistently). Please choose as many options as you are able.

Did you know we can work with your child's school to coordinate our appointment during the school day to limit travel time disruptions? Are you interested in filling out our school-based mental health form to explore options?
Do you have a preference for in-person or online services? Research shows they are equally effective and our professional staff is skilled in both!
Do you have a preference for in-person or online services? Research shows they are equally effective and our professional staff is skilled in both!
Do you have a location preference?
If you prefer in person appointments, do you have a location preference?
When is the best time to reach you?
Please enter a day/time that you would be available for us to call you, in order to schedule an appointment.
Is there anything else you would like us to consider when choosing a therapist for you?
Thank you! We will do a courtesy check of your insurance benefits if you are planning to use insurance, and then reach out to you via your phone or email to get you scheduled!

One More Important Step:

Please add appointments@bhcwausau.com and appointments_plover@bhcwausau.com to your contacts!
We hate spam and unsolicited emails as much as you do. Unfortunately, our emails can incorrectly get filtered as spam, which may affect our ability to communicate with you

Adding appointments@bhcwausau.com and appointments_plover@bhcwausau.com to your contacts and/or approved sender list will help ensure our important emails land in your inbox and not your spam folder.

We look forward to working with you. Please feel free to meet our team by visiting wibehavioralhealth.com
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Request for Services

Insurance Information

Counseling Preferences