Initial Appointment Request

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

Marital status *

I'm filling this request out for *

Myself
My spouse/partner
My child
Other

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.

What is your relationship to the prospective client? *

Your Name *

First

Last

Your 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.

Your Email *

To be used for notifications from our offices regarding Patient Portal instructions, statements and 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 [Not Currently Available]
Couples Counseling [Not Currently Available]
Group Therapy/Workshops (we currently are running the Adult Anxiety and DBT Groups)
Biofeedback for Medical/Chronic concerns
Biofeedback for psychological concerns

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? (can select more than one) *

Tell us about your availability for regular therapy sessions:

Flexible, and will be able to make most times work (This option can be scheduled quickest)
I have a very rigid daytime schedule and require evenings if available
It's more complicated (Please fill in the box 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, .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 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 appointments@insightpsychgroup.com in order for our offices to review your registration.

New Client Appointment Request Form

We currently have the following availability to accept new patients:

How can we help?

Payment/Insurance Information

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