Revised Appt Request Draft

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Insurance Lookup

(FOR OFFICE USE ONLY)

Today's Date *

Client's Name *

First

Last

(Legal name)

Client's Date of Birth *

Client's Age *

Please select sex *

For insurance purposes

Gender Identity

(optional)

Preferred pronouns

(optional)

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 [currently unavailable]
Other

Your insurance Is

Important Message:

When a child is brought to our practice for therapy and the parents are not married, we will require the written consent of both custodial parents in order to provide services.

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

Person filling out this form

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.

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? *

Were you referred by any practitioner specifically for Biofeedback services? *

Yes
No

Name of practitioner who suggested Biofeedback

(All communication with outside practitioners will require client's prior written consent)

Please elaborate on your interest in our Biofeedback services

Which group(s) were you interested in attending or learning more about?

Please check all the items below that describe your situation: *

Have you ever had previous therapy/counseling of any kind? *

Yes, once
Yes, a few times
No

Has the client ever had previous therapy/counseling of any kind? *

Yes, once
Yes, a few times
No

Is your child currently attending school? *

Yes, regularly
They skip school when symptoms are bad
Refusing to go to school
Is not allowed back at school without a psychiatric evaluation

Important Message:

Our practice conducts therapy and counseling. Typically return-to-school requires an evaluation by an MD or Psychiatric APN. Hi Focus Centers (877) 561-9633 has several locations in New Jersey that can quickly provide this kind of evaluation.

Are you/Is the client prescribed medication for any of the above conditions? *

Yes
No
I'm hoping you can prescribe or re-prescribe medications

Important Message:

Our practice consists only of psychotherapists/psychologists, counselors and therapy specialists. We do not prescribe medication at all. Please consult your provider directory for a list of psychiatrists or psychiatric nurse practitioners in your area.

Are there any current restraining orders in place within in the couple/family? *

Yes
No

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

Yes
No

Are you or your family member being required by an outside party to seek treatment at this time? *

Yes
No

How compliant is the client with taking this medication as prescribed? *

Perfectly	Somewhat compliant	Not very compliant	Has stopped taking it on one's own
PerfectlyPlease rate Perfectly	Somewhat compliantPlease rate Somewhat compliant	Not very compliantPlease rate Not very compliant	Has stopped taking it on one's ownPlease rate Has stopped taking it on one's own

Does the client currently have trouble with drugs or alcohol? *

Yes
No

Please choose which best describes the drug/alcohol use: *

Significant difficulties with drugs or alcohol, and I/we are simultaneously looking for help with it
Currently in drug/alcohol treatment
It's a problem together with the psychological issues; I don't know which is worse
Would like treatment from your offices for drug/alcohol problems

Important Message:

While some substance use or overreliance on alcohol can occur in the context of emotional and psychological struggles, if the substance or alcohol use has become your predominant problem, you will need to seek services at a specialized drug/alcohol treatment center, such as Hi Focus or Gen Psych in New Jersey. Our practice does not specialize in drug or alcohol abuse treatment.

(Sensitive questions follow)

Are you concerned about your or anyone else's safety in your home? *

Yes
No

Have you ever had thoughts that you would be better off not living anymore? *

Yes, currently
Yes, but only in the past
No

Have the client ever had thoughts that they would be better off not living anymore? *

Yes, currently
Yes, but only in the past
No

Important Message:

Unfortunately, our practice is not emergency services or urgent care. If you or your family member are currently experiencing these thoughts and feelings, call an urgent care center right away: Mobile Response 877-652-7624 will usually be able to send a team out to you within an hour. The suicide and crisis helpline is simply 988. Confidential urgent helpline for teens: 888-222-2228. And dialing 911 or just going to your nearest ER is always a safe option.

Have you ever had thoughts of harming yourself? *

Yes, currently
Yes, but only in the past
No

Has the client ever had thoughts of harming themselves? *

Yes, currently
Yes, but only in the past
No

Important Message:

Unfortunately, our practice is not emergency services or urgent care. If you or your family member are currently experiencing these thoughts and feelings, call an urgent care center right away: Mobile Response 877-652-7624 will usually be able to send a team out to you within an hour. The suicide and crisis helpline is simply 988. Confidential urgent helpline for teens: 888-222-2228. And dialing 911 or just going to your nearest ER is always a safe option.

Have you ever been hospitalized for psychiatric reasons or substance abuse? *

Currently in inpatient or intensive outpatient treatment (IOP), looking for therapy once discharged
Yes, discharged within the past 30 days
Within the past year
More than a year ago
More than 5 years ago
No

Has the client ever been hospitalized for psychiatric reasons or substance abuse? *

Currently in inpatient or intensive outpatient treatment (IOP), looking for therapy once discharged
Yes, discharged within the past 30 days
Within the past year
More than a year ago
More than 5 years ago
No

Important message

We will require discharge paperwork in order to proceed with our intake process. With written consent, your caseworker can also reach out to us.

Please elaborate on your reason for seeking help at this time:

Who needs the treatment, brief background to seeking help right now, current issues... *

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

Click here to see details of our office locations.

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 [Currently unavailable]
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

We ask for your detailed information here so that we can quickly respond to your request regarding our participation in your plan's network

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.

This web form is secure and encrypted to protect your privacy Your information is kept strictly confidential

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How can we help?

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Please elaborate on your reason for seeking help at this time:

Payment/Insurance Information

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