CCOSA (NEW CLIENT)

DISCLAIMER: Due to COVID-19 our office has seen an influx in requests for services. The availability of licensed counselors that accept insurance has been limited. When you submit your interest -- a front desk representative will contact you after 2:00pm Monday thru Friday (if not sooner) and let you know the current availability. Please note we do have Licensed Professional Counselor Associates and Masters Level Student Counselors available at affordable rates along with flexible scheduling. Thank you for your understanding during this period of high demand.

Will you be using Insurance or Private Pay?*

If choosing Private Pay, we have THREE discount options (not required).

All Discount plans with our Counselor Associates or Student Counselors require a valid credit card on file.

If using insurance, are you the Primary Insured or Dependent? (Private Pay clients are always the primary insured)

PRIVATE PAY CLIENTS ARE ALWAYS PRIMARY.

What is the FIRST and LAST NAME of the Primary Insured?

Date of Birth of Primary Insured*

Age of Client*

NAME OF CLIENT (if different from primary insured)*

Date of Birth (if different from primary insured)*

Gender *

Marital Status*

Home Address*

City/State/ZIP*

Phone Number*

Email Address*

Insurance Company Name*

LPC Associates and Student Counselors CANNOT accept insurance (Low Rates Available - Select Private Pay)

Policy ID/Subscriber ID/Member ID [IF PRIVATE PAY, please enter DOB in the following format -- MMDDYYYY]*

Group Number (If applicable)

Mental Health or Provider Relations Phone number (If applicable, it can be located on the backside of the insurance card or type N/A)*

Please write N/A if NOT using insurance

EAP Authorization Number (If applicable)

Please indicate number of approved sessions

What service are you seeking?*

Do you have any preferences regarding therapist (i.e. date/time, specialty, language, specific counselor name, etc)

Briefly describe what brings you into counseling?*

Do you prefer TELEHEALTH or Face-to-Face?

Telehealth OnlyFace-to-Face OnlyNo preference

Are you interested in FREE Group Therapy or Support Groups?*

YESNOMAYBE

DISCLAIMER: All fully licensed counselors are INDEPENDENT providers and DO NOT BILL under Counseling Connections of San Antonio. Some exceptions apply. Feel free to contact our office for more details.

MESSAGE [Optional] (attempt to include name, phone number, email [if available], detailed message, and good day/time to call back):

How did you find Counseling Connections of San Antonio?*

Upload Front/Back Copy of Insurance Card (if desired)

Browse Files

COVID-19 SCREENING:*

I am fully vaccinated.I am partially vaccinated.I have been vaccinated and boosted.I have experienced illness in the last 14 days.I have been exposed to someone sick in the last 14 days.I am not vaccinated.Other

Enter the message as it's shown*

Disclaimer: We are not privy to the provisions of your health plan (if applicable). The information is located with your employer health benefits that was given to you or mailed to your home. The insurance companies do not mail benefit booklets to the physician’s office however, please note ANY benefits quoted from our office are not a guarantee of payment.

IF YOU HAVE NOT BEEN CONTACTED WITHIN 24 business hours of your submission, please call our office at 210-446-8255.

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