New Client Scheduling Form

First Name *

Last Name *

Phone *

Email *

Client’s name (if different) *

Relationship to Client *

Client’s DOB *

Type of Counseling *

Individual

Couples (if you have Medicaid insurance couples is not a covered benefit)

Family

If Couples, please list your partner’s first and last name, date of birth, and email address

Please provide a timeframe you are available for counseling *

Please share your preference on who you would like to see *

Briefly Describe The Issue You Would Like to Work On *

INSURANCE VERIFICATION

Primary Insurance

If your insurance does not exist in the list or if you have an EAP, please choose "Others" and add the information in the additional information box below.

Policy Holder’s Name *

Policy Holder’s Date of Birth *

Group # *

Relationship to the Client *

Insurance ID or RIN # *

Customer Service Phone # *

Insurance Benefit Disclaimer *

As a courtesy, we will get a general quote of your benefits. Based on the information received, we will inform you of what your out of pocket costs will be within one business day. Please understand that benefits are subject to all contract limits and the member’s status on the date of service and the information provided is not a guarantee. Actual coverage and member liability amounts will be determined when the claim is processed. This is not a pre-authorization or a guarantee of payment. Accumulated amounts such as deductible, out of pocket may change as additional claims are processed. Also, not all clinicians are covered by all insurance plans offered at Pivotal Counseling Center. If you have specific questions about your coverage, we recommend that you also contact your insurance carrier directly.

Please share any additional information you feel would be helpful *

Email Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Pivotal Counseling Center therapists and/or office staff communicating with me via email or text message

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