• New Client Set-Up

    New Client Set-Up

  • Is the person submitting this form the Client?*
  • Format: (000) 000-0000.
  • Submitter's Relationship to Client*
  • Age Range of Client*
  • How did you hear about Therapy Resources?*
  • Has the DATE/TIME of the initial appointment already been identified?*
  • What type of service is being requested?*

  • Client Information

  • Client's Date of Birth*
     / /

  • Contact information MUST be for the CLIENT

    If the client is 13 years or younger, one parent's email address and phone number can be used for the client
  • Format: (000) 000-0000.

  • Availability & Preferences

  • Indicate type of service preference:*
  • Rows

  • Insurance Information

  • Primary Subscriber's Relationship to Client*
  • Primary Subscriber's Date of Birth
     - -
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  • 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
     - -
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  • Billing Information

  • 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.
  • Should the Financial Guarantor be included in the initial Scheduling process?

  • For clients aged 18 and older, the client will need to sign a set of Release of Information forms to include any other individual in the scheduling process!

    If these forms are not completed and signed, we will not be able to discuss the intake/scheduling process with anyone other than the client themself.
  • 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.

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