Provider Request Form "*" indicates required fields Client Name* First Last Client Legal Guardian Name* First Last Guardian Email* Guardian PhoneClient Date of Birth* MM slash DD slash YYYY Preferred Language*EnglishSpanishAmerican Sign LanguageClient Insurance Carrier*AetnaAnthem BlueCross BlueShieldCignaMedicaidSliding Scale Out-of-PocketUnited Health CarePLEASE NOTE: If this client has out-of-network insurance but would be interested in paying out of pocket, please select “Sliding Scale Out-of-Pocket” from the choices below.Insurance Member IDPolicyholder Full NamePolicyholder Date of Birth MM slash DD slash YYYY Policyholder Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Client Address (if different from policyholder) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Why type of support are you seeking? Individual Therapy Individual Therapy for Child or Teen Couples Therapy Family Therapy Which location would work best for this client?*Virtual Sessions in ColoradoVirtual Sessions in PennsylvaniaDenver, COWheat Ridge, COSouth Aurora, COSouth Lakewood, COWestminster, COPittsburgh, PAPlease indicate briefly if there are any therapist preferences our intake team should be aware of. (e.g. gender, area of specialty, etc.)Please provide a timeframe for ideal start date.Please attach client face sheet (or any other applicable information) Drop files here or Select files Max. file size: 40 MB, Max. files: 5. Your Name First Last Email If you would like us to communicate with you as we go through the scheduling process, please provide us with your name and an email that you can be reached at.NameThis field is for validation purposes and should be left unchanged.
