New Client INTAKE Form

New Client Request Form

Please complete this form to request services. Not all providers are currently accepting new clients, but once submitted, our office will contact you with available options.
Please select the services you are requesting to begin with:*

CounselingMedication Management
Who are these services for?*
This form must be completed by the individual seeking services, or by the legal guardian if the client is a minor.
HOW DID YOU HEAR ABOUT US?:*

FacebookInstagramFamily or FriendAdvertisement
Name of Family or Friend that referred you?

First NameLast Name
Are you requesting the free 15‑minute initial consultation for community heroes?*
Available for teachers, nurses, EMS, police, firefighters, veterans, and active‑duty military.
Describe your verification type (badge, work ID, military ID, etc.)
Upload Proof (Optional)

You may upload a photo or screenshot of your verification (e.g., badge, work ID, DD214, military service screenshot).
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- If you are completing this form on behalf of a minor, please note the following:
  - This form must be completed by a legal guardian only.
  - You are required to upload a copy of your valid driver’s license at the end of this form.
  - The legal guardian(s) must attend the minor’s first appointment to:
    
    Complete any additional required documentation
    
    Meet the provider
  Additionally:
  - If there is an active or finalized custody agreement or ongoing custody dispute, documentation outlining legal rights and decision-making authority must be:
    
    Uploaded with this form
    
    Brought to the minor’s first appointment
  Failure to comply with these requirements may delay the scheduling or continuation of services.

Patient Demographic Information

This section is for the demographic information of the individual seeking to become a new client.
Are you the legal guardian of the client?*

YesNo
Please enter your information: (Legal Guardian / Person Completing Form)*
Client Name*

First NameLast Name
Date of Birth*
Age:*
Gender*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Social Security #
Address (Mailing)*

Street Address

Street Address Line 2

CityState

Zip Code

Insurance Information

We do NOT accept Medicare at this time. We are actively working on becoming In‑Network, but until then, if you have Medicare—or any insurance we do not accept—please select the Self‑Pay option to continue. If you have EAP sessions: Please still enter your regular insurance information on this page. This ensures that once your EAP sessions are used, we can continue your care without interruption. You will be able to enter your EAP details on the next page.
Do you have insurance?*

YesNo, I will be SELF PAY
Primary Insurance:*
If you do not see your insurance, please select Other.
1. Choose your Medicaid Plan Name:
OTHER Insurance Name:*
Member ID/Policy Number (Primary)*
Policy Holder*

SelfOther
Relationship to client:
Policy Holder Name:*

First NameLast Name
Policy Holder DOB*

MonthDayYear
Date
Policy Holder SSN #
Primary Insurance
Do you have secondary insurance?*
Secondary Insurance:
2. Choose your Medicaid Plan Name:
Member ID/Policy Number (Secondary)

- Employee Assistance Program
  
  An Employee Assistance Program (EAP) is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems.
- Do you have EAP Benefits through your insurance that will be covering your appointments?
  
  YesNo
- EAP Company Name: The EAP Company is NOT the name of your Employer Company - (If unsure, type N/A and be sure to provide us with an EAP Company phone number below)
- EAP Company Phone Number - *If applicable*:
  Please enter a valid phone number.
- EAP Authorization # and/or MAT #:
  Required for us to bill EAP sessions. If you were not provided one by your insurance company, please call them to initiate an EAP Authorization and receive your Authorization # / MAT #.
- # of EAP Sessions Approved:
  How many sessions were approved to be billed under you EAP Authorization.

Reason For My Request
Is this service Court Ordered?

YesNo
⚠️ Disclaimer (Paragraph Element Below the List):

Important Insurance Notice:
Most court-ordered counseling is not covered by insurance when it is for legal purposes. Whether services can be billed to insurance depends on the specific court order and what is being requested.
If you upload and submit your documentation, we will review it and have that information ready when we call to schedule your appointment.
Court Ordered - Additional Information:
What are a few BRIEF reasons you are seeking counseling/med management?*
This helps us better understand your needs and match you with the most appropriate provider. You may keep your response brief—details can be discussed during your first appointment.
If there is any additional information you would like to add, please do so here...
Feel free to include any details you believe may help us better understand your needs or situation. This section is optional.
- Would you prefer a Male or Female Provider?
- If accepted, is there a certain day and/or time that would be best to schedule you?
- Counseling - Requesting Provider to be scheduled with:
  If your are not sure, once you submit on your Intake, a member of our staff will choose a provider we think will best fit you!

Final Step: Upload Your Documents

If you upload all required documentation now, you will not need to bring these items to your first appointment. This helps us verify your information in advance and streamline your intake process.
- Driver's License/I.D. (FRONT)
  
  (if a patient is a minor, upload Guardians)
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- Driver's License/I.D. (BACK)
  
  (if a patient is a minor, upload Guardians)
  Cancelof
- Primary Insurance (Front)
  
  Cancelof
- Primary Insurance (Back)
  
  Cancelof
- Secondary Insurance (Front)
  
  Cancelof
- Secondary Insurance (Back)
  
  Cancelof
- Custody Agreement or Legal Documentation
  
  Cancelof
- EAP Authorization Confirmation
  
  Cancelof
- Other
  
  Cancelof

Review Your Intake Before Completing
Should be Empty:

New Client Request Form

Patient Demographic Information

Insurance Information

Employee Assistance Program

Reason For My Request

Final Step: Upload Your Documents

Review Your Intake Before Completing