Provider Portal | Center for Resilience Strategies

Provider Request Form

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Client Name*

Client Email*

Client Phone

Client Legal Guardian Name (if applicable)

Guardian Email (if applicable)

Guardian Phone

Client Date of Birth*

Preferred Language*

Client Insurance Carrier*

PLEASE 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 ID*

Policyholder Full Name*

Policyholder Date of Birth*

Policyholder Address*

Street Address City State ZIP Code

Client Address (if different from policyholder)

Street Address City State ZIP Code

Please indicate if you have any other health insurance coverage. If not, write N/A.

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?*

Please 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

Max. file size: 40 MB, Max. files: 5.

Your Name

First Last

Your Email