Request an Appointment

If you are interested in services at Bright Path Counseling and Consulting LLC, please submit the information on this form and you will be contacted by a member of our team in a timely manner. The email address will be used to send you patient portal access to view and sign all paperwork electronically, as well as service surveys throughout your journey with us as a part of exceptional client care.

Email *

Will this inquiry be for you or are you making a referral for someone else?

Myself or a minor under my care

I am making a referral for someone

Client Information

If you are not the client, please answer the questions below in regards to the client that will be seen at Bright Path Counseling and Consulting, LLC. Our Client Care Coordinator will be in touch very soon to talk to you more about scheduling your first appointment.

Please tell us how you heard about us *

If you heard about us from a source other than those listed above, how did you hear about us?

Your First Name *

Your Last Name *

Child's Name

Mailing Address of Patient *

City *

Zip Code *

Patient email address if 16 years old or older or Parent/Guardian email address

Patient's Date of birth *

Patient Age Group *

Patient phone number if 18 years old or older or Parent/Guardian phone number *

What is the best time(s) of day to contact you for scheduling? *

Morning

Afternoon

Evening

May we send you text messages? *

Yes

May we send you emails?

Yes

If you will be using insurance, what type(s) of insurance do you have? *

Above is a list of insurances currently accepted or billed at Bright Path Counseling and Consulting, LLC

If you have Medicaid, what is your Medicaid number?

If you have a private or commercial insurance policy, what is your Member ID?

Name of the policy holder and DOB (often this is a parent for commercial policies).

Do you have a secondary Insurance? *

Yes

If you answered Yes, Who is the secondary insurance Provider, the Member ID and/or Policy/Group Number? Secondary insurance information cannot be skipped and if not accurate could result in denied claims.

Reason for Referral

In what location would you prefer to be seen? *

Is there a particular provider that you are requesting? First Choice

Is there a particular provider that you are requesting? Second Choice

What are the primary concern that you are seeking services for? *

If you selected other, please tell us why you are seeking counseling services at this time.

Is there anything else we should know before scheduling your first appointment? I.e., Do you have limited availability?

I agree that Bright Path Counseling and Consulting, LLC. may receive the information above electronically and may communicate with me. I understand that this form is not a guarantee of services. I also understand that email and SMS transmissions are capable of being intercepted, and privacy of any confidential information that is sent or received cannot be absolutely guaranteed. I agree to the terms, risks, and limits.