Intake Request Form_Lavender Rose

Lavender Rose Behavioral Health PLLC

430 W Warner Rd, B105, Tempe, AZ 85284 | Phone: (480) 405-4510 | Fax: (480) 781-4842 office@lavenderrosebehavioralhealth.com
NEW INTAKE REQUEST FORM
Welcome to Lavender Rose Behavioral Health, where "Healing Minds, Blooming Lives" is at the heart of what we do. We are honored that you are considering us for your care. Please complete the form below to request an appointment. At this time, we are only accepting new patients for medication management.

Note: Submitting this form is a request only and does not guarantee an appointment until confirmed by our office.
Patient & Appointment Information
Patient name*

First NameLast Name
Date of birth*

MonthDayYear
Age*
Is the patient a minor?*

YesNo
If patient is a minor, please input the full name of the responsible adult completing this form*
Relationship to the patient*
Phone number*
Email*
How did you hear about us?*

Provider ReferralFamily/FriendsPsychology TodayGeneral Online SearchOther
Who referred you?*
Reason for the appointment. *
List any current diagnoses. Type N/A if not applicable*
List any current medications. Type N/A if not applicable*
Preferred type of appointment for the initial visit*

In-officeTelehealth/Virtual
Preferred days & times for the initial visit *
Note: This is not your confirmed date of visit. This information will help us find a schedule that matches your preference with the provider's availability
Insurance & Payment Information
NOTE:
- We currently accept Cigna, Blue Cross Blue Shield, Aetna, Carelon Behavioral Health, and Quest Behavioral Health.
- Our credentialing with United Healthcare (UHC) plans is still in progress. Patients who wish to schedule before credentialing is completed may choose to self-pay. Once credentialing is finalized, patients will have the option to switch to insurance billing for future visits.
- We are not credentialed with Medicare or Medicaid (AHCCCS). Therefore, services provided at this clinic will not be billed to these programs. Patients who have Medicare or Medicaid coverage may choose to receive services on a self-pay basis. By doing so, they acknowledge that they are personally responsible for all charges incurred and cannot seek reimbursement from their insurance plan.
Do you have insurance?*

YesNo, I will self-payI have UHC coverage but choose to self-pay until credentialing is complete, with the option to switch to insurance billing once available.I have Medicare coverage but choose to self-payI have Medicaid coverage but choose to self-pay
Self-Pay Policy Acknowledgment

By choosing self-pay, I acknowledge and agree to the following terms:
- I am responsible for the self-pay rate of $250 for the initial evaluation and $125 for each follow-up appointment, unless an alternative payment arrangement has been established and approved in advance.
- I agree to securely enter and maintain my payment information in Alma, a HIPAA-compliant platform used for billing and payment processing, to ensure the timely and secure collection of fees.
- I understand that payment is due at the time of service unless otherwise specified.
Insurance carrier*
Member ID*
Group No.*
Name of the primary subscriber*

First NameLast Name
Date of the birth of the primary subscriber*

MonthDayYear
Address associated with your insurance plan*

Street Address

Street Address Line 2

CityState

Zip Code
Upload the FRONT of the insurance card*

Cancelof
Upload the BACK of the insurance card*

Cancelof
Upload your ID (Upload parent's ID if patient is a minor)*

Cancelof
Consent & Signature
I understand that submitting this form is a request for an appointment and does not establish a patient-provider relationship until I am scheduled and seen by a provider. I hereby certify that all information provided in this form is true, accurate, and complete to the best of my knowledge. I understand that providing false or misleading information may affect my care or eligibility for services.
Signature of the Patient/Parent /Legal Guardian:*

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Date Signed*

MonthDayYear
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Lavender Rose Behavioral Health PLLC

NEW INTAKE REQUEST FORM

Patient & Appointment Information

Insurance & Payment Information

Consent & Signature