Patient Registration FormMost answers are required so we can properly review your request. After filling out the form, we will follow up with you, via e-mail or phone, within 1-2 business days.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Insurance LookupTo be verifiedOn holdGood to go(FOR OFFICE USE ONLY)Today's Date *I am filling this form out: *To register myself or a family member for therapy (individual/couples/family)To register myself or a family member for Group Course participationTo register myself or a family member for Biofeedback servicesTo register myself for Parent Coordination or Divorce Mediation ServicesMy therapist or IPG Staff asked me to fill this form out.I was referred by Project EzrahClient's Name *FirstLast(Legal name, as your insurer would have it)Client's Date of Birth *Client's Gender *Client's Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMarital status *Please selectSingleMarriedDivorcedWidowedOtherI'm filling this request out for *MyselfMy spouse/partnerMy childOtherWhat 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 *FirstLastPhone *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 *FirstLastPhone *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 CounselingIndividual Child CounselingCouples CounselingGroup Therapy/Workshops (we currently are running the Adult Anxiety and DBT Groups)Biofeedback for Medical/Chronic concernsBiofeedback for psychological concernsWhat are you looking for help with? *AnxietyDepressionMarital/Relationship issuesCommunication issuesCoping with painChronic illnessPTSDAnger managementGriefParentingOCDPhobias/FearsSchool or child behavior issuesWorkplace problemsLife adjustment/Career concernsPlease 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) *WestfieldMaywoodSpringfieldLittle FallsI am fine with Telehealth sessions if that is all that's availableI only want sessions by telehealthTell 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 availableIt's more complicated (Please fill in the box below)Paragraph TextHow did you first hear about us? *Internet SearchInsurance ListPsychology TodayGood TherapyTherapy TribeMy psychiatristI'm a former client of IPGWord of mouthMy primary care doctorProject EzrahIs there anything else that would be helpful for us to know?Payment/Insurance InformationHow will you be paying for treatment? *Please selectI need to stay in my insurance networkI would like to use my insurance, but am willing to go out of network if necessaryFee-paying. I don't want to use my insuranceProject Ezrah Program (even so, if you are insured, please add your information below so we can determine any reiimbursement)Special Program for families impacted by the War in IsraelClient's relationship to primary insurance holder *SelfSpouse/PartnerChildOtherName 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 OnlyPlease 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 OnlyCheck 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 *Please selectYes (please fill in below)NoClient's relationship to secondary insurance holderSelfSpouse/PartnerChildOtherName of secondary insurance holderDate of birth of secondary insurance holderSubscriber/Member ID#Secondary Insurance CompanyPlease 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 OnlyPlease 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 OnlyCheck 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. Submit
