New Patient Prescreener

New Patient Prescreen
Patient Name
If child, parent name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth
Gender
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Insurance Company
Insurance member ID
Insurance group ID
Subscriber name and date of birth
Billing and Insurance Verification

Sunrise Counseling Services uses Headway for insurance billing and verification for select insurance plans. After completing this prescreener, you may receive an email from Headway asking you to enter your insurance information.

This step is required so we can confirm whether we accept your insurance before scheduling an appointment. Please complete the Headway information as soon as possible to avoid delays in scheduling.

What are your goals for treatment
Is there anything else you would like our office to know
Provider and location for requested services
Thank you for contacting Sunrise Counseling Services, PLLC. Someone from our office will contact you shortly.
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