Initial Appointment Request - Insight Psychological Group

Insurance Lookup

(FOR OFFICE USE ONLY)

Today's Date *

Client's Name *

First

Last

(Legal name, as your insurer would have it)

Client's Date of Birth *

Client's Gender *

Client's Address *

Address Line 1

Address Line 2

City

State

Zip Code

you you Text

Marital status *

I'm filling this request out for *

Myself
My spouse/partner
My child
Other

What is your relationship to the prospective client? *

Client's Phone *

Best number to reach the client directly, and to receive texts from our office concerning scheduling or billing.

Client's Email *

To be used for notifications from our offices regarding Patient Portal instructions, statements and forms to fill out.

Your Name *

First

Last

Phone *

Best number to reach you, and to receive texts from our office concerning scheduling or billing.

Your Phone *

If we have any questions about the information on this form.

Email *

For confirmation of receipt of this form, as well as notifications from our offices regarding Patient Portal instructions, financial statements and any forms to fill out.

Your Email *

For confirmation of receipt of this form and if we have any questions.

Emergency Contact *

First

Last

Phone *

Relationship to patient *

Parent, spouse, partner, aunt, uncle, cousin, friend...

How can we help?

Most answers are required so we can better understand how best to assist you.

What type of services are you looking for? *

Individual Adult Counseling
Individual Child Counseling
Couples Counseling
Group Therapy (please see our Group Therapy page for groups we are currently offering)
Biofeedback for Medical/Chronic concerns
Biofeedback for psychological concerns

Are there any current restraining orders in place between the parties in the couple? *

Yes
No

Please explain... *

Is there any current DCP&P involvement in your family? *

Yes
No

Please explain... *

What are you looking for help with? *

Please elaborate on your reason for seeking help *

(i.e. who needs the treatment, background, current issues...)

Which offices could you drive to weekly if in-person sessions are available? (select all that apply) *

Tell us about your availability for weekly therapy sessions: *

Almost any time during the week will work
I can't do daytime appointments and would like an evening time (short waiting list)
My availability is more complicated (please explain in the box that appears below)

Paragraph Text

How did you first hear about us? *

Is there anything else that would be helpful for us to know?

Payment/Insurance Information

How will you be paying for treatment? *

Client's relationship to primary insurance holder *

Self
Spouse/Partner
Child
Other

Name of primary insurance holder *

Date of birth of primary insurance holder *

Subscriber/Member ID# *

Primary Insurance Company *

Please upload a copy/pic of your insurance card (front) *

Click or drag files to this area to upload. You can upload up to 2 files.

.PNG, .JPG, .JPEG, .DOC, or .PDF Format Only

Please upload a copy/pic of your insurance card (back) *

Click or drag files to this area to upload. You can upload up to 2 files.

.PNG, .JPG, .JPEG, .DOC, or .PDF Format Only

Check if you are unable to upload your insurance cards.

If you are unable to upload a picture of your insurance cards, then after submitting this form you will need to email them to appointments@insightpsychgroup.com in order for our offices to review your registration.

I have secondary insurance coverage *

Client's relationship to secondary insurance holder

Self
Spouse/Partner
Child
Other

Name of secondary insurance holder

Date of birth of secondary insurance holder

Subscriber/Member ID#

Secondary Insurance Company

Please upload a copy/pic of your insurance card (front)

Click or drag files to this area to upload. You can upload up to 2 files.

.PNG, .JPG, .DOC, or .PDF Format Only

Please upload a copy/pic of your insurance card (back)

Click or drag files to this area to upload. You can upload up to 2 files.

.PNG, .JPG, .DOC, or .PDF Format Only

Check if you are unable to upload your insurance cards.

If you are unable to upload a picture of your insurance cards, then after submitting this form you will need to email them to billing@insightpsychgroup.com in order for our offices to review your registration.

(continuously updated)

Current therapist availability status:

New Client Appointment Request Form

How can we help?

Payment/Insurance Information