Adult Request for Services
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Can we use this phone number to send appointment confirmation text(s)?
*
Yes
No
Please provide a phone number that we can text for appointments.
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referral Name: If you were referred by someone (e.g. , Primary Care, School Counselor, Search Engine, Social Media, Friend/Family), please provide their name and the name of their organization.
*
Referral Name
Referral Organization
Have you ever been diagnosed with a mental health condition?
*
Yes
No
Have you previously received counseling?
*
Yes
No
Briefly describe the challenges you hope to resolve in therapy:
*
Which type of appointment do you prefer virtual or in person?
*
In person
Virtual
Either
Preferred days/times for counseling:
*
Rows
N/A
Morning
Afternoon
Evening
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please provide any additional information you would like (number of household members to participate, transportation limitations, etc) :
*
Do you have insurance?
*
Commercial insurance - BCBS, CIGNA, Humana, etc..
Medicaid (Wellpoint, Parkland, CHIP)
EAP
Private Pay
No
EAP Authorization #
*
EAP authorization letter must be uploaded to receive services
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Insurance Provider Name
*
Insurance Information
*
Group ID
Member ID
Policy Holder's Name
*
First Name
Last Name
Policy Holder's DOB
*
-
Month
-
Day
Year
Date
Attach a Driver's License / State ID
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Front of Insurance Card must be uploaded to receive services
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back of Insurance Card must be uploaded to receive services
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are you seeking a discount for services?
*
Yes
No
Sliding Fee Discount Information
It is the policy of Hamilton Counseling and Consulting to provide essential services regardless of the patient’s ability to pay. HCC offers discounts based on family size and annual income. Please complete the following information to determine if you or members of your family are eligible for a discount. The discount will apply to all services received at this clinic. You must complete this form every 12 months or if your financial situation changes.
Source (Annual Income for all in the Household Members)
*
Rows
Self
Other
Total
Gross, wages, salaries, tips, etc.
Income from business and self-employment
Unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, veterans' payments, survivor benefits, pension, or retirement income
Interest; dividends; royalties; income from rental properties, estates, and trusts; alimony; child support; assistance from outside the household; and other miscellaneous sources
TOTAL INCOME
Income verification: Applicants may provide one of the following: prior year W-2, two most recent pay stubs, letter from employer, or Form 4506-T (if W-2 not filed). Self-employed individuals will be required to submit detail of the most recent three months of income and expenses for the business.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please list all household members, including those under age 18.
*
Rows
Full Name
DOB (MM/DD/YYY)
Self
Other
Other
Other
Other
Other
Other
Other
I certify that the family size and income information shown above is correct.
*
Submit
For Office Use Only
Patient's Name
First Name
Last Name
Approved Discount
Approved by:
Approved Date:
-
Month
-
Day
Year
Date
Should be Empty: