• Registration form for new clients

    Hope Behavioral Health

  • Welcome to Hope Behavioral Health.

    In an effort to quickly and efficiently connect you with a therapist, this registration form collects all necessary and required information in order to begin counseling services.  It only takes about 5-10 minutes to complete.

    Please note:

    • If the individual seeking services is under the age of 18, this form must be completed by a parent/legal guardian.  
    • You will need to upload copies of your driver's license and insurance cards (if you have insurance) before submitting this form.

    Once this form has been submitted, we will contact you as quickly as possible.  Upon receipt of your insurance information (if applicable), we will make every effort to verify your benefits and provide you with your projected out-of-pocket cost at your initial session. However, we strongly recommend you call your insurance company and verify your benefits for outpatient mental health services.

    If you have any questions, please contact our intake department at (800) 642-4560, option 1.

    Thank you,

    Intake team
    Hope Behavioral Health

    *All information is transmitted and stored securely and privately using JotForm, conforming to HIPAA standards.

  • Overview

  • Is the individual seeking services 18 years or older?*

  • Please note:

    This form must be completed by a parent/legal guardian.

  • Will insurance be used for services?*

  • *Please note:

    It is required that you provide all insurances a client is covered by and indicate the order in which they are to be billed. Any discrepancies in relationship to this coordination of benefits will result in claim denials. This will be covered in the insurance sections below.

  • Does client have secondary insurance?*
  • Will you be using an EAP for services?
  • Do you have your insurance card(s) with you?*

  • Please note:

    Before submitting this form, you will need to upload a picture of the front AND back of your insurance card(s).

  • How did you hear about us?*

  • Client information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Client gender*
  • Client marital status*
  • Client employment status*
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  • Is the family currently involved in custody or divorce proceedings?*
  • If yes, has a Guardian ad Litem (GAL) been assigned?*
  • Is there any legal documentation pertaining to the identified client (i.e. guardianship, custody, etc.)?*
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  • Parent/guardian information

  • Format: (000) 000-0000.
  • Is minor client up to date on immunizations? *Please know that immunization status does not and will not impact a client’s ability to receive care in office or virtually.*
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  • Patient preferences

  • NOTE: If you are interested in faith-based therapy, please keep in mind that although all of our therapists operate from a spiritually sensitive ethical position, not all of them incorporate faith-based principles in treatment. To ensure that you are assigned a therapist who is competent in this area, be sure to let us know here so that we can match you with a therapist to best meets your goals.

  • Do you wish to incorporate faith-based components (e.g. Biblical counseling and/or prayer) in your therapy sessions?*
  • If the above location preference is unavailable, are you open to traveling to the next closest office location?
  • If the above location preference is unavailable, are you open to telehealth?
  • If your above preferred therapist(s) is unavailable or availability does not match, may we match you with a therapist based on the information provided?

  • *Please visit http://www.hopebehavioral.com/therapists to see which therapists work out of a particular office.


    *Assignment of therapists is ultimately subject to therapist and office availability as well as insurance contracts.  We will make every effort to honor your preferences, but cannot guarantee it.  Thank you for your understanding as we work to link you with a compatible provider.

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  • Primary insurance information

    Upon receipt of insurance information, our office will make every effort to verify your benefits and provide you with your projected out-of-pocket cost at your initial session. We would strongly recommend you call your insurance company and verify your benefits for outpatient mental health services. Some questions to consider asking: Do I have mental health insurance benefits? What is my deductible and has it been met? How many sessions per year does my health insurance cover? Is prior approval required from my primary care physician?
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  • Policyholder date of birth (if not client)
     - -
    2 digit month, 2 digit day, 4 digit year

  • Secondary insurance information

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  • Policyholder date of birth (if not client)
     - -
    2 digit month, 2 digit day, 4 digit year

  • *All information is transmitted and stored securely and privately using JotForm, conforming to HIPAA standards.

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