Patient's Name
First Name
Last Name
Patient's Birthdate
-
Month
-
Day
Year
Date
Patient's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance
Aetna
BCBS
BCN
Cigna
HAP
McLaren
United Health Care
Priority Health
Private Pay
Primary Insured ID
Group Number
Primary Insured Name
First Name
Last Name
Relationship to Patient
Self
Parent
Spouse
Primary Insured Birthdate
-
Month
-
Day
Year
Date
Primary Contact Name
First Name
Last Name
Primary Contact Email (Client's email if 18 or older)
example@example.com
Primary Contact Phone Number
-
Area Code
Phone Number
Referral Source
Preferred Therapist (click all that apply):
No Preference
Aimee Monticello
Renee Romer
Brooke Polakowski
Albana Metaj
Lori Kola (daytime and/or virtual only)
Brittany Davis (daytime only)
Amanda Locke (booked)
Andrea Grew (booked)
Karley Tholen (booked)
Katrina Motrinc (booked)
Lauren Bongiorno (booked)
Matt MacLellan (booked)
Days/times you prefer:
General issues you would like to see covered:
Individual Counseling
Family Counseling
Couples Counseling* (Only Lauren offers this type of counseling and her schedule is only open for daytime openings)
Anxiety
Depression
Substance Abuse
Autism/Aspergers
School/work related concerns
Other
In person or virtual:
In person
Virtual
Combination of both
Submit
Should be Empty: