Self-Referral / Prospective Client Inquiry

Dr. Alex Rivera-Fernandez, Ph.D.,LLC

www.beyondstigmas.org / 1-888-344-9069
Self-Referral / Prospective Client Inquiry

Please complete this form to inquire about our services. Submitting this form does not guarantee services or establish a therapist-client relationship. This form is hosted through a HIPAA-enabled Jotform account used in support of the practice’s HIPAA-compliant operations. Information submitted through this form is intended to be collected, transmitted, and stored using safeguards designed to support HIPAA compliance. For emergencies, call 911 or go to the nearest emergency room.
Client Contact Information
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Insurance Information
Insurance Company*
Member ID Number*
Group Number
Insurance Effective Date*

MonthDayYear
Date
Subscriber Name (if different from client)
How did you hear about the practice?
Requested Services
Type of Service Requested*
Reason for Referral*
Additional Information and Acknowledgment
Additional information you would like to share
I confirm the information provided is accurate to the best of my knowledgeI understand this is an inquiry form and not an emergency service
Should be Empty:

Dr. Alex Rivera-Fernandez, Ph.D.,LLC