Client Intake Form
Thank you for requesting an appointment. Please complete this form, which goes directly to our Client Care Specialist who typically responds within 24 - 48 hours.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How would you like to be contacted?
*
Email
Phone
Text
Briefly state your reason for seeking therapy.
*
Please select your health insurance provider.
*
Optum
United Healthcare
CDPHP
MVP
Aetna
BlueShield of Northeastern NY
Highmark
Anthem (formerly Empire Bluecross)
OTHER
If your insurance isn’t listed, and you selected OTHER, Evergreen may not be in network with your provider, however we can still submit claims on your behalf. Please let us know what insurance provider you currently use.
Insurance Member ID #
*
Where did you hear about Evergreen MHC?
*
Submit
Should be Empty: