Therapy Health Clinic PLLC

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Date of birth

Sex at birth

For insurance verification

State

Select the state you live in

Billing Address:

Reason for care

What kind/ format of care is being requested (Individual/ Couple/ Family/Group)?

Individual Psychotherapy Family/ Couple's Therapy Employee Assistance Program (EAP/ Work Sponsored) EAP Authorization Reqd. Group Therapy (Workshop)

Mental Health State & Most Recent Mental Health History

Have been Hospitalized or received therapy for mental health reasons in the past Taking psychiatric medication currently or in the past In crisis or in-danger of causing harm to yourself or others None of these apply

Administrative

Referral source

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Medical Insurance Name/ Network (BCBSIL PPO, Aetna, Cigna, United, etc)

Provide the insurance name here as written in the insurance card including specific network PPO/HMO Medicare Advantage *if BCBSIL*

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

IF USING MED. INSURANCE CARD: Member ID Number (Insurance Card Number):

Insurance Member ID:

IF USING EAP, Provide EAP COMPANY NAME

(Compsych/Guidance Expert, Optum, Curalinc/ Amtrak, EverNorth, CCA, etc) Write Name of EAP network here::

IF USING EAP, Must have an EAP Authorization/ Referral Code:

VERIFICATION: If unable to upload Insurance/ EAP details: Client can text/email the insurance Card photo of their insurance card (front & back picture) to Admin @ 708-888-0491/ email admin@therapyhealthclinic.com

If unsure/ unable to give agent the insurance or EAP referral code, client must follow-up/ contact the office by phone/ email within 24-48 hours after scheduling for Insurance/ EAP verification. Pls. text the EAP code and EAP network (If applicable). If using Medical Insurance: Upload the photo of the insurance card (front and back) via email to admin@therapyhealthclinic.com or TEXT 708-888-0491

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Preferred clinician

Select a clinician from the list

Preferred modality

Is there anything that the practitioner needs to know ( If Group Therapy/ Workshop which workshop are you interested in?)

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.