Website Submissions- Darby Integrative- New Client Questionnaire

Client's Identifying and Contact Information
Client's Legal First and Last Name (On the Insurance Policy)*

First NameLast Name
Optional: Client's Preferred Name/Nickname:
Client's Legal Sex:*

MaleFemaleNon-BinaryOther
Client's Date of Birth*

MonthDayYear
Date
Client's Best Phone Number(s):*
Please enter a valid phone number.
Client's Legal Postal Address: (Street Address, City, State, Zip Code):*

Street Address

Street Address Line 2

CityState

Zip Code

In the event of an emergency, who is the closest contact to you?

Note: This person will ONLY be contacted in the event of an emergency.
Client's Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
The State that the Emergency Contact is located in.*

Client's Insurance Information
Your Insurance Provider?*

Blue Cross Blue Shield (Carefirst, Federal Employee Program, BCBS of any state, etc)United Behavioral Health or Government Employees Health Association (GEHA)CignaAetnaMedicare or MedicaidNo InsuranceOther
If you have insurance, please enter the following from your insurance card:
1. ID Number*
2. Group Number *
3. Phone Number for Providers on the Back of the Insurance Card *
Please attach a copy of the front and back of your Insurance Card:

Cancelof
I agree to be referred to an Out of Network Therapist. (Please Note: There is a waitlist for all in-network therapists. We cannot guarantee a time frame for openings with these providers. If you choose to be on the waitlist, we will contact you as soon as an appointment becomes available).
*The amounts per sessions are dependent on your insurance company.*

Your therapist will give you a quote for services at the time of your free phone consultation. To obtain your insurance information and your out of pocket costs, call the member number on the back of your insurance card or log into your insurance portal.
I have questions/concerns about the cost of treatment:
Please provide the following information so we may best assist you: *
Your Out of Network Deductible for Individual and Family; the Allowed Amount Per Sessions (CPT Codes 90791, 90837, 90834, 90847) Your Coinsurance, and Your Out of Pocket Maximum for Sessions
I would like to continue completing this form and be matched with a specialized therapist as soon as possible:*

YesNo: Please save your responses and call 301-960-8694 so that we may address any questions prior to form completion.

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Darby Integrative Counseling

Please Provide the Following Information

Client's Identifying and Contact Information

In the event of an emergency, who is the closest contact to you?

Client's Insurance Information

If you have insurance, please enter the following from your insurance card:

Treatment Preferences

Optional Questions