Request for Service with Auxilium

Request for Service

Use this form if you would like to request therapy from Auxilium.
Client Contact Information

PLEASE NOTE: If you're requesting therapy for your child, the child's information should be entered as the "Client" below.
Client Full Legal Name*

First NameMiddle NameLast Name
Is the client under the age of 18?*

YesNo
What name does the client go by?*
Client's Date of Birth*

MonthDayYear
Date
What is the client's gender?
Client's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Client's Email Address*
Is it okay to use this email to send you appointment reminders?

YesNo
What is generally the best way to contact the client?

By EmailBy Phone
Custody Information
Do both biological parents live in the home?

YesNo
Please explain custody arrangement if applicable:
Please upload any relevant custody documentation.

Accepted file types - pdf, doc, docx, jpg, jpeg, png / Max File Size 10Mb
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Parent/Guardian #1 Information
Does Parent/Guardian #1 have full custody of the child?

YesNo
Parent/Guardian #1

First NameLast Name
Parent/Guardian #1 Date of Birth

MonthDayYear
Date
Parent/Guardian #1 Gender

FemaleMale
Parent/Guardian #1 Emergency Contact

YesNo
Parent/Guardian #1 Portal Access

YesNo
Parent/Guardian #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Email
example@example.com
Is it okay to use this email to send appointment reminders?

YesNo
What is generally the best way to contact this parent/guardian?

By EmailBy Phone
Add an Additional Parent/Guardian?

YesNo
Parent/Guardian #2 Information
Parent/Guardian #2

First NameLast Name
Parent/Guardian #2 Date of Birth

MonthDayYear
Date
Parent/Guardian #2 Gender

FemaleMale
Parent/Guardian #2 Emergency Contact

YesNo
Parent/Guardian #2 Portal Access

YesNo
Parent/Guardian #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Email
example@example.com
Is it okay to use this email to send appointment reminders?

YesNo
What is generally the best way to contact this parent/guardian?

By EmailBy Phone
Insurance Information
Do you have insurance coverage?*

Primary Insurance CoveragePrimary and Secondary Insurance CoverageNo Insurance Coverage
Who pays for this insurance policy?

The person who has been added to the "Client Contact" section of this form.The insurance policy is paid by a different person (or a parent/guardian).
Policy Holder Name

First NameLast Name
What is the client's legal gender? (your sex/gender on record with your insurance company?*

FemaleMale
Policy Holder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder Email Address
example@example.com
Policy Holder Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Applicant
Policy Holder Date of Birth

MonthDayYear
Date
Primary Insurance Provider
Policy #
Member ID#
Group ID#
Please provide the "Provider Phone Number" on the back of the insurance card.
Please enter a valid phone number.Format: (000) 000-0000.
Upload a photo of the front of your insurance card

Accepted file Types - pdf, doc, docx, jpg, jpeg, png, gif / Max Image Size 10mb
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Upload a photo of the back of your insurance card

Accepted file Types - pdf, doc, docx, jpg, jpeg, png, gif / Max Image Size 10mb
Cancelof
Secondary Policy Holder Name

First NameLast Name
Secondary Policy Holder Date of Birth

MonthDayYear
Date
Secondary Insurance Provider
Policy #
Member ID#
Group ID#
Please provide the "Provider Phone Number" on the back of the insurance card.
Please enter a valid phone number.Format: (000) 000-0000.
Upload a photo of the front of your insurance card

Accepted file Types - pdf, doc, docx, jpg, jpeg, png, gif / Max Image Size 10mb
Cancelof
Upload a photo of the back of your insurance card

Accepted file Types - pdf, doc, docx, jpg, jpeg, png, gif / Max Image Size 10mb
Cancelof
Therapy Services
Current/Previous Therapy Services*
Reasons for seeking services*
Is there any current legal or Dept. of Child Services (DCS) involvement?*

YesNo
Please provide more information on the DCS involvement.
Have you applied for or are you seeking a disability?*

YesNo
Do you have a gender preference?*

Male clinicianFemale clinicianNo Preference
Which is your preference for a therapist?*

I want to work with a specific therapist.I would like to work with a specific therapist, but I am open to working with another therapist.I don't have a preference. I would prefer the first available therapist.
If selected, which therapist(s) do you prefer?
Please Note:

A preference for a specific therapist will likely affect the amount of time that you have to wait. If your preference selected should change to first available, please contact our office to notify us.
Which method of services delivery do you prefer?*

In PersonTelehealthUnsure
Your Appointment Preferences
What are your preferred day(s) of the week for sessions?*

MondaysTuesdaysWednesdaysThursdaysFridaysFirst Available
What are your preferred times of day for sessions?*

Early Morning 9:00am - 11:00amMidday 11:00 - 1:00pmEarly Afternoon 1:00pm - 3:00pmLate Afternoon 3:00 - 6:00pmFirst Available
Additional Questions
How did you hear about Auxilium?*
Please Note the Following:

Once you click the "submit" button below, you will receive a confirmation email that your request for service has been received. You will be put on our waitlist and will be contacted only when an appointment with a provider who takes your insurance is available.

Thank you for your patience.
Should be Empty:

Request for Service

Client Contact Information

Custody Information

Parent/Guardian #1 Information

Parent/Guardian #2 Information

Insurance Information

Therapy Services

Your Appointment Preferences

Additional Questions