Your Information/Information Please

If you are using Insurance please enter the following information in the box below:

Insurance Company Name

Insurance ID #

Your Workplace

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Please call your insurance company to be sure you're covered under "Specialist" services. Also check your co-pay and deductible. This will help avoid potential problems later. 

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If you are using Employee Assistance Program behefits please enter the following information in the box below:

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Name of EAP (Value Options, Cigna, etc)

EAP Authorization #

Number of sessions

Dates that sessions are valid

Your Workplace

Questions or concerns? Please let us know and we'll get back to you as soon as possible

By checking the box below I (client) agree and understand that:

• My counselor will keep my information in complete confidence

• All appointments and copays will be paid in advance

• TeleTherapy sessions are for personal therapy only and these sessions/records will not be used for obtaining Disability Benefits, Social Security benefits, or for court cases