Client Intake Request Form
We're glad that you chose That's Crazy Mental Health LLC. Our mission is to shift the stigma regarding mental health. We currently accept all major insurance. Please fill out this form in its entirety. We look forward to following up with you!
Client Full Name
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date
Client Contact Number
*
Please enter a valid phone number.
Client Email Address
*
example@example.com
New Client?
Yes, new client
No, returning client who needs to provide update information
Is client's age under 18 years old?
*
Yes
No
Parent/Guardian Full Name
For clients under 18
Parent Phone Number
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
Parent Date of Birth
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Type of Services
*
Individual Therapy
Group Therapy
Couples/Family Therapy
Not sure. I would like a consultation to learn more
Therapy Groups
"Faith and Feelings" led by Ashley Lucas (8 weeks. Starting March 17 Sundays 6pm-7pm) Age 18+
"Female Athletes Support Group led by Raven Hicks (Monthly. Starting Saturday March 16 2:30-3:30 pm) Age 18+
"Teens from Military Families" Therapy Group led by Symone Jackson (Every other Wednesday from March 20th to May 15th) Age 12-15
Reason for seeking services:
*
Example: loss of a loved one, divorce, childhood trauma, etc...
Payment
Incorrect or missing information will delay appointment scheduling and client onboarding. If your insurance is not listed, please write it in. We may still accept your insurance. Self-pay clients will input their payment information when they fill out their Client On-Boarding forms to schedule their appointment.
Payment Type
*
Insurance
Self-Pay
Employee Assistance Program (EAP)
Select Insurance
*
Please Select
Aetna
Anthem
Blue Cross Blue Shield
Cigna
Florida Blue
Humana
Optum
Surest (formerly Bind)
Tricare
United Healthcare
Other Unlisted (write name of insurance below)
Other unlisted insurance
Insurance Type
Please Select
HMO
PPO
Medicaid
Medicare
Employment-based
Insurance ID
Group Insurance ID
EAP Company
Please Select
ComPsych
Health Advocate
Curalinc
Cigna EAP
Aetna EAP
Optum EAP
BHS
AllOne Health
EAP Authorization Number or Referral Code
Upload Picture of Insurance Card
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