• Appointment Request Form

  • Is the person submitting this form the Client?*

  • Services are set up in the name of ONE person (sometimes referred to as the “primary client”).

    • For services with multiple participants, the primary client is usually* the participant whose needs are being most directly addressed.

    *ATTENTION: The primary client must be a beneficiary of the insurance policy being used.

    *Services with multiple participants can be processed in the name of a different participant if necessary for insurance coverage.

  • Submitter's Relationship to Client*
  • Format: (000) 000-0000.
  • How did you hear about Therapy Resources?*
  • What type of service is being requested?*
  • Age Range of Client*

  • INDIVIDUAL COUNSELING services are focused on the needs of one individual client, who is generally* expected to be present for the duration of services.

    *The provider may request to include additional family members, depending on the individual's needs; any involvement of other individuals would remain focus on the client's needs.

  • Clients aged 13 and under: Parents/legal guardians are implicitly involved in services, with one parent/guardian serving as the primary contact for the client. 

    *Additional parents/guardians can be included as needed*

  • Clients aged 14 through 17: The client themself must be included in the intake process for confidentiality reasons; at least one parent/guardian must also be included for scheduling purposes.

    *Additional parents/guardians can be included as needed*

    • Once an appointment/provider option has been offered, the client themself must respond to confirm and schedule.

  •  Clients aged 18 and older: For confidentiality reasons, only the client themself is involved in the scheduling process (unless the client requests otherwise).

    • If the client chooses to include any other individuals in the scheduling process, they must first sign a Release of Information (ROI) Authorization for each individual.

  • COUPLE'S/MARITAL COUNSELING services are focused on the needs of the relationship as a unit, and are generally* expected to include all participating partners for the duration of treatment.

    *The provider may request to meet with individual partners alone as needed, with the focus remaining on the relationship (rather than any individual). 

     

    Reminder: For insurance purposes, services are processed in the name of one partner, sometimes referred to as the "primary client."

    • The primary client must be a beneficiary on the insurance plan being used; if all partners are not covered under the same policies, the request must be processed in the name of the partner whose insurance will be used.

    *Unless otherwise stated, only the listed primary client will be included in the scheduling process*

  •  

    FAMILY COUNSELING services are focused on the needs of the family as a unit, and are generally* expected to include all participating family members for the duration of treatment.

    *The provider may request to meet with different combinations of family members depending on the need, with the focus remaining on the full family unit.

     

    Reminder: For insurance purposes, services are processed in the name of one participant, referred to as the "primary client."

    • The primary client must be a beneficiary on the insurance plan being used; if all participants are not covered under the same policy, the request must be processed in the name of the participant whose insurance will be used.

     

  • Primary Client 13yo or younger: One participating parent/legal guardian will serve as the PRIMARY CONTACT for services. 

    *Additional participants can be included in the scheduling process as needed*

  • Primary Client 14yo through 17yo: While one participating parent/legal guardian can serve as the PRIMARY CONTACT for services, the PRIMARY CLIENT themself must also be included in the scheduling process for confidentiality reasons.

    *Additional participants can be included in the scheduling process as needed*

    • Once an appointment/provider option has been offered, the PRIMARY CLIENT themself must respond to confirm and schedule.

  •  Primary Client 18yo or older: Unless otherwise stated, only the PRIMARY CLIENT themself will be included in the scheduling process (unless otherwise requested).

    *Additional participants can be included in the scheduling process as needed*

  • While IDRC sessions are billed through insurance, IDRC requirements include additional reporting fees that are not submitted to insurance-- including the Initial NJSAMS Assessment and report, as well as monthly follow-up reports.

    • Total reporting fees over the course of treatment will be approximately $525* - based on a rate of at $175/hour for 4 hours of reporting over a standard 4 month period.
      *If treatment and reporting exceeds 4 months/4 hours, you can expect this amount to increase in by $175/hour.*

     

  • PAYMENT

  • Do you have EAP (Employee Assistance Program) benefits for these services?*

  • ATTENTION: Not all of our providers are able to accept EAP benefits!

    *If using EAP benefits, primary insurance information is also required for placement.*

  • Are you open to not using EAP benefits?*
  • Would you like to provide your EAP details now or later?*

  • While not required for the scheduling process, EAP details MUST be on record by the time of an appointment in order to apply coverage.

    ATTENTION: Our providers are not able to accept EAP benefits through all insurance companies; full details are required to verify acceptance! 

  • EAP Primary Subscriber*
  • EAP Subscriber Date of Birth:
     - -
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  • Are you using insurance for these services?*

  • Out-of-Pocket/Self-Pay Services

    For services without the use of insurance, we offer the following out-of-pocket rates:

    Initial Assessment (all service types): $300 (30-90min)
    Individual Sessions: $175 - Couple's/Marital/Family Sessions: $235

    *Sessions are expected to be 60 minutes unless otherwise indicated*

    Once an initial appointment is identified, a Self-Pay Financial Agreement must be signed before the appointment can be confirmed!

     

  • INSURANCE

  • To avoid interruption to services, the initial appointment CANNOT be scheduled until we receive all insurance details (including images of the FRONT and BACK of the card)!

    *Our practice is in-network with most major insurance payers; upon receipt of your plan details, we will notify you if our practice is not in-network*

    ATTENTION: While we prefer to verify our practice's in-network status prior to identifying a provider, clients are ultimately responsible for understanding their own coverage.

    • To independently verify the in-network status of our providers, contact your insurance company's member services and use our practice's NPI (1881936847) to identify our providers.

     

  • Would you like to provide your/the client's insurance details now or later?*

  • If you choose to submit the insurance details at a later time, a new link will be sent to you via email to finalize your Appointment Request! 

    *We will begin the process of identifying a provider/appointment upon receipt of THIS form, but the NEW form will be required to SCHEDULE any offered appointment* 

  • Primary Insurance Subscriber:*
  • Primary Insurance Subscriber Date of Birth:
     - -
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  • Is the client a beneficiary on a secondary insurance policy?*

  • Secondary Insurance Information

  • Secondary Insurance Subscriber:*
  • Secondary Insurance Subscriber Date of Birth:
     - -
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  • CLIENT INFORMATION

  • Info - IND

    [for backstage reference only]

  • For clients under the age of 14, one parent/guardian will be the primary contact for the intake process; additional parents/guardians can also be included as requested.

  • Format: (000) 000-0000.
  • Should any additional parent/guardian(s) be included in the scheduling process?*

  • Info - IND 14-17

    [for backstage reference only]

  • For clients aged 14 through 17, the client themself must be included in the intake process-- in addition to at least one parent/guardian.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Should any additional parents/guardians be included in the initial scheduling process?*

  • Info - IND 18+

    [for backstage reference only]
  • Format: (000) 000-0000.
  • Should anyone (other than you) be included in the initial scheduling process?*

  • *not recommended for INDIVIDUALS over 18*

    Note: Clients over the age of 18 are required to must sign a Release of Information Authorization to allow anyone access to the details of their request/services.

  • Info - REL

    [for backstage reference only]

  •  

    Couple's/Marital Counseling Services are set up in the name of ONE partner (sometimes referred to as the "primary client"). *Additional partners can be included in the intake process as requested*

  • Format: (000) 000-0000.
  • Do you want to include any partners in the initial scheduling process?*

  • Info - FAM

    [for backstage reference only]

  • Family Counseling Services are set up in the name of ONE participant (sometimes referred to as the "primary client").

    For (primary) clients under the age of 14, ONE parent/guardian will serve as the primary contact for services.

    *Additional parents/guardians/participants can be included as requested.*

  • Format: (000) 000-0000.
  • Should any additional family members/participants be included in the intake process?*

  • Info - FAM 14-17

    [for backstage reference only]

  • Family Counseling Services are set up in the name of ONE participant (sometimes referred to as the "primary client").

    For (primary) clients aged 14 through 17, the (primary) client themself must be included in the intake process-- in addition to at least one parent/guardian.*

    *ONE parents/guardian required; others can be included as requested.*

     

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Should any additional parents/guardians/participants be included in the initial scheduling process?*

  • Info - FAM 18+

    [for backstage reference only]

  • Family Counseling Services are set up in the name of ONE participant (sometimes referred to as the "primary client").

    For (primary) clients aged 18 and older, only the (primary) client is included in the intake process, unless otherwise requested.

     

  • Format: (000) 000-0000.
  • Do you want to include any participating family members in the initial scheduling process?*

  • Info - IDRC

    [for backstage reference only]
  • Format: (000) 000-0000.
  • Should anyone (other than you) be included in the initial scheduling process?*

  • *not recommended for clients over 18yo*

    Note: Clients over the age of 18 are required to sign a Release of Information Authorization to allow anyone other than themself access to the details of their request/services.

  • Provider Placement

    NOTE: The purpose of this form is to identify an appropriate provider NOT to determine the treatment process; a (more thorough) set of New Client Forms will later be required for provider review.

  • Placement - IND

    [for backstage reference only]
  • Please select the PRIMARY reasons for seeking services: (up to 5)*
  • Please select any contributing and/or additional reasons for seeking services:*
  • Is the client currently in, or have they recently* discharged from, a higher level of care?*
  • To ensure appropriate placement and treatment, we will later require a copy of the (most) recent Discharge Summary. Do you have access to this?*

  • Placement SPECIFIC - IND

    [for backstage reference only]
  • Has your child (or any immediate family members) received services with Therapy Resources of Morris County in the past or currently?*

  • Placement SPECIFIC - IND 14-17

    [for backstage reference only]
  • Has the client (or any immediate family members) received services with Therapy Resources of Morris County in the past (or currently)?*

  • Placement - IND 18+

    [for backstage reference only]
  • Please select the PRIMARY reasons you are seeking services: (up to 5)*
  • Please select any contributing and/or additional reasons you are seeking services:*
  • Are you currently in, or have you recently* discharged from, a higher level of care?*
  • To ensure appropriate placement and treatment, we will later require a copy of your (most) recent Discharge Summary. Do you have access to this?*
  • Have you (or any immediate family members) received services with Therapy Resources of Morris County in the past (or currently)?*

  • Placement - REL

    [for backstage reference only]
  • Please select the PRIMARY reasons you are seeking Couple's/Marital counseling: (up to 5)*
  • Please select any contributing and/or additional reasons you are seeking Couple's/Marital counseling:*
  • Are you or your partner(s) currently in, or recently* discharged from, a higher level of care?*
  • To ensure appropriate placement and treatment, we will later require a copy of the (most) recent Discharge Summary. Do you/your partner(s) have access to this?*
  • Have you/your partner(s) or any immediate family members received services with Therapy Resources of Morris County in the past (or currently)?*

  • Placement - FAM

    [for backstage reference only]
  • Please select the PRIMARY reasons you are seeking family counseling: (up to 5)*
  • Please select any contributing and/or additional reasons you are seeking family counseling:*
  • Are any participating family members currently in, or recently* discharged from, a higher level of care?*
  • To ensure appropriate placement and treatment, we will later require a copy of the (most) recent Discharge Summary. Do you have access to this?*
  • Have any participating or immediate family members received services with Therapy Resources of Morris County in the past (or currently)?*

  • Placement - FAM 18+

    [for backstage reference only]
  • Please select the PRIMARY reasons you are seeking family counseling: (up to 5)*
  • Please select any contributing and/or additional reasons you are seeking family counseling:*
  • Are any participating family members currently in, or recently* discharged from, a higher level of care?*
  • To ensure appropriate placement and treatment, we will later require a copy of the (most) recent Discharge Summary. Do you have access to this?*
  • Have any participating or immediate family members received services with Therapy Resources of Morris County in the past (or currently)?*

  • ALL SERVICES EXCEPT IDRC

  • Are these services related to a court order?*
  • Are there any other parties (e.g. attorneys) involved in these services?*
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  • This request cannot be processed without a copy of the related court order (to ensure appropriate placement).

    *If we do not receive a copy of the court order along with this form, we will follow up with you by email*

  • A Release of Information (ROI) Authorization will later be required to allow your family's provider to communicate with any outside parties/legal counsel.

    You may also be required to sign a separate release through the outside party, to allow them to communicate with the provider in return.

  • Placement - IDRC

    [for backstage reference only]
  • What county is processing your referral?*
  • If applicable, select UP TO 5 contributing/additional reasons you are seeking services:
  • Have you (or any immediate family members) received services with Therapy Resources of Morris County in the past (or currently)?*

  • SCHEDULING

  • Our physical office located at 25 Lindsley Drive Suite 300, Morristown NJ 07960 - if requesting IN-OFFICE or HYBRID services, please consider travel time!

    • For HYBRID services, appointments are available IN-OFFICE by default, with the option of VIRTUAL appointments as needed.

    REMINDER: Services are generally expected to be held on a weekly basis, at the same day/time -- unless otherwise discussed.

    • Provider schedule flexibility varies-- if you are not available for consistent weekly appointments, please let us know!

    **Our providers are not able to offer EMERGENCY/SAME-DAY services; if this is a psychiatric emergency, please call 911 or visit our Emergency Resources (click here) page!**
     

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