Counseling Intake Request- F.A.M Healing Center

Counseling Intake Request- F.A.M Healing Center

Please complete this form to request outpatient mental health counseling services at F.A.M Healing Center. Our intake team will review your information, verify insurance or self-pay arrangements if applicable, and contact you to schedule your appointment.This form is not monitored for emergencies.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*

Confirmation EmailConfirm Email
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What City are you located in?*
Preferred Service Location*

Las Vegas (In-Person)Pahrump (In-Person)Telehealth (Nevada Residents Only)
What type of counseling are you seeking?*

Individual CounselingCouples CounselingFamily CounselingFaith-Based CounselingEquineAssisted TherapyOther
What are you seeking counseling for? (Select all that apply)*

AnxietyDepressionTrauma/PTSDStress/BurnoutRelationship concernsFamily IssuesLife transitionsGrief/LossSubstance AbuseOther
Payment Type*

InsuranceSelf-Pay/Private PayEAP
Insurance Information
Insurance Carrier
Member ID or Authorization Reference Number for (EAP)
Upload Governmental ID*

Cancelof
Upload Front of Insurance Card or EAP Referral

Cancelof
Upload back of insurance card

Cancelof
I understand that insurance benefits must be verified prior to scheduling and coverage is not guaranteed.
Self-Pay Counseling
I understand that if I am requesting self-pay counseling services and that payment is due at the time of service unless otherwise arranged.
Any question regarding self-pay or fees?
Are you currently experiencing thoughts of harming yourself or others?*

NoYes
If you are experiencing thoughts of harming yourself or others, please seek immediate help.

Call 911, go to the nearest emergency room, or contact the Suicide & Crisis Lifeline by calling or texting 988.
Please share your general availability or preferred days/times for appointments.
Referral Source*

SelfCourtAttorneyWebsiteInsurance CompanyOther
Consent & Acknowledgment*

I understand this form is a request for services and does not guarantee an appointmentI consent to be contacted by F.A.M Healing Center regarding counseling servicesI confirm I am seeking outpatient Mental Health or Substance Use Therapy services
Should be Empty:

Counseling Intake Request- F.A.M Healing Center

Insurance Information

Self-Pay Counseling