Request Therapy Client Information This is the person who will be receiving services. First Name Middle Initial Last Name Date of Birth Gender Select Male Female Referred By Parents/Guardian Information First Name Middle Initial Last Name Email Address Date of Birth Street Address City Zip Code State Country Home Phone Work Phone Mobile Phone Marital Status Select Single Engaged Married Widowed Divorced Diagnosis Upload Images Name of the doctor that diagnosed your child Date of Diagnosis Payment Source Medicaid Medicaid # Initial consent to services Select Yes No Card Upload Upload your card images Front of the card Back of the card Signature Upload Upload your signature image Insurance Company Name Select Able Center Aetna Ambetter Amerigroup Allsavers American Behavioral Arbor Village GH Cigna Humana Private Pay Medicare Medicaid Molina health United health Other Insurance Card Holder Name Date of Birth Last 4 digit of insured SSN Member Number Group Number Card Upload Upload your card images Front of the card Back of the card Select Language English Other Send
