• Returning Appointment Request Form

    Returning Appointment Request Form

  • Is the person submitting this form the Client?*
  • Format: (000) 000-0000.
  • Submitter's Relationship to Client*
  • Age Range of Client*
  • Has the client turned 18 years old since the last date of services?*
  • Has the client turned 14 years old since the last date of services?*

  • Changes for Clients 14yo through 17yo

    For clients aged 14 through 17, federal and state confidentiality laws dictate that client consent is required for any parent/guardians to access certain types of medical information (such as drug & alcohol, mental health, reproductive health and certain diseases).

  • As such, the client's existing account must be updated to reflect the CLIENT as the primary user, and at least ONE parent/guardian as financial guarantor!

    • Unless otherwise indicated, only the CLIENT will have access to the full set of required forms; the financial guarantor's access will be limited to billing/financial information!
    • Multiple parents/guardians can be included in the intake process and/or on the account using the Additional Users section at the end of this form.

    **If the client would like ANYONE other than themself (including the financial guarantor) to have FULL ACCESS to the account, they (the client) will need to sign a set of Release of Information forms for each individual!**

  • Changes for Clients now 18+

  • Now that the client is over the age of 18, the client's existing account must be updated to reflect the CLIENT as the primary user (if not done already)!

    • By default, only the CLIENT will be included on scheduling emails/have access to the account!
    • If the client would like ANY parents/guardians to be included in the intake process and/or on the account, they must be included as Additional Users section (at the end of this form).

    **If the client would like ANYONE other than themself to be included in the intake process and/or on the account, they (the client) will need to sign a set of Release of Information forms for each individual!**

  • Returning Client Update...

  • Has the client's insurance information changed since the last services with Therapy Resources?*
  • Has the billing information/financial responsibility changed since your last services with Therapy Resources?*
  • Should anyone other than the client themself (as reported) be included in the intake process and/or have access to the Patient Portal account (i.e. parents/guardians, partners)?*

  • Client Information

  • Contact information MUST be for the CLIENT* themself!

    (*If the client is 13 years or younger, one parent's email address and phone number can be used for the client)
  • Client's Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Has the client's street address changed since the services with Therapy Resources?*

  • Address Update (If Applicable)

  • Schedule Update (If Applicable)

  • Rows
  • Indicate type of service preference:

  • Insurance Information (If Applicable)

  • Primary Subscriber's Relationship to Client*
  • Primary Subscriber's Date of Birth
     - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Is the client a beneficiary on a secondary insurance policy?*

  • Secondary Insurance Information

  • (2nd Ins) Primary Subscriber's Relationship to Client
  • (2nd Ins) Primary Subscriber's Date of Birth
     - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Billing Information (If Applicable)

  • Please indicate who to contact for payment and other financial matters:
  • Financial Guarantor's Relationship to Client
  • Financial Guarantor's Date of Birth
     - -
  • Format: (000) 000-0000.
  • Do you want the Financial Guarantor have access to the client's patient portal?

  • For clients aged 14 and older, the client will need to sign a set of Release of Information forms to allow any individual to have full access to the client's account.

    If Release Forms are not received, access will be REMOVED or LIMITED to Financial Only.

  • To help ensure confidentiality and placement with an appropriate provider...

  • Is the client being discharged or has the client recently been discharged from a higher level of care?*
  • Are there/will there be any other parties (e.g. attorney, DCP&P, etc.) involved in these services?*

  • Additional User #1

    NOTE: The purpose of an Additional User is to assist with the completion of the required forms and/or have access to client financial information (if applicable). If Release of Information Forms are required, they will be sent via the Patient Portal.

  • Relational Counseling: If you’re requesting Couple’s or Marital services and would like to include a partner in scheduling or portal access, list their name and access level below.

    Note: If the client is over 18, they must complete all forms themselves. Additional users will only have viewing access unless two Release of Information forms are signed.

  • Family Counseling: If you’re requesting Family Counseling and want to include additional family members in scheduling or portal access, list their name and access level below.

    Note: Access rules vary based on whether the client is under or over age 14. See the next section for specific requirements.

  • Client Under 14 Years Old: If the client is under 14 and a parent/guardian other than the listed Guarantor wants to be included in scheduling or portal access, list their name and access level below.

  • Client 14 Years or Older: If the client is 14 or older and wants a parent/guardian other than the listed Guarantor included in scheduling or portal access, list their name and access level below.

    Note: The client must sign two Release of Information forms to grant full portal access to others.
  • Additional User #1's Relationship to Client*
  • Should Additional User #1 be included in the Intake and Scheduling process?*
  • (1a) Should Additional User #1 have access to the Patient Portal account?*
  • (1b) What patient portal access should Additional User #1 have?*
  • Additional User #1's Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Do you have a second additional user to include?*

  • Additional User #2

    NOTE: The purpose of an Additional User is to assist with the completion of the required forms and/or have access to client financial information (if applicable). If Release of Information Forms are required, they will be sent via the Patient Portal.
  • Additional User #2's Relationship to Client
  • Should Additional User #2 be included in the Intake and Scheduling process?
  • (2a) Should Additional User #2 have access to the Patient Portal account?
  • (2b) What patient portal access should Additional User #2 have?
  • Additional User #2's Date of Birth
     - -
  • Format: (000) 000-0000.
  • Do you have a third additional user to include?

  • Additional User #3

    NOTE: The purpose of an Additional User is to assist with the completion of the required forms and/or have access to client financial information (if applicable). If Release of Information Forms are required, they will be sent via the Patient Portal.
  • Additional User #3's Relationship to Client
  • Should Additional User #3 be included in the Intake and Scheduling process?
  • (3a) Should Additional User #3 have access to the Patient Portal account?
  • (3b) What patient portal access should Additional User #3 have?
  • Additional User #3's Date of Birth
     - -
  • Format: (000) 000-0000.

  • To include more additional users to these services, please email our Intake Department at intake@therapyresourcesmc.com. Please include the requesting Client's name and Date of Birth to ensure the information is going to the correct client.

  • Should be Empty: