School Based Request for Services

Request for Services

For for School-Based Services DCE
We are ready to help you!
- First, we need insurance information so we can help you understand your benefits.
- We also need you to sign our consent to treatment policies, and our cancellation and now show policies so that you understand what we can and cannot do as part of treatment.
- We will follow up with a history questionnaire that is very helpful for you to fill out as completely as possible prior to the first appointment.
This is a secure, HIPAA compliant form. Your privacy and confidentiality is our priority.
Date

MonthDayYear
Date
Client's Preferred Name

First NameLast Name
Client's Gender Identity or Pronouns
Legal Name of Client (as listed on insurance)*

First NameLast Name
School *
Grade*
Client's Date of Birth*

MonthDayYear
Birthdate
MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian Name (First and Last)*
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*
Please enter a valid contact email. By providing an email you give us permission to email you with forms and with appointment reminders.
I have health insurance and would like to use it for counseling.I plan to pay out of pocket and will not be using insurance.
Insurance Information
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
Date
Where Insured is Employed
Please complete the following if you have a Secondary Insurance Plan. If you do not, you may leave this section blank.
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
Date
Where Insured is Employed
Please describe reason for referral
Current Interventions (at school or home)
Thank you!

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

Request for Services

Insurance Information