Change of Provider

Change of Provider Form
By completing and signing this form, I acknowledge and understand that I wish to change my mental health provider from my current agency to Heart and Solutions, LLC.
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
BHISTherapy
Current Agency, if not Heart and Solutions
Insurance Provider*
Insurance Number or ID*
Signature*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Change of Provider Form