THIS REGISTRATION IS NOT FOR EMERGENCIES. IF YOU HAVE AN EMERGENCY, CALL 911 OR VISIT YOUR NEAREST EMERGENCY ROOM.
Registrations are processed in the order they are received. Before we contact you to schedule your first appointment, we must first verify your insurance benefits (if you are using insurance), determine your copays and deductibles, and identify a clinician who fits your needs. This may take several days, so please be patient.
We will contact you by email, so please check your inbox frequently.
If you are completing this only to sign/re-sign the Client-Provider Agreement or to provide new insurance information, complete items 1-14 and then skip to the appropriate items. Indicate in item 14 that is the reason you are completing the form.
Client Information:
1. First Name *
1.
*
First Name
2. Last Name *
2.
*
Last Name
3. Date of Birth *
3.
*
Date of Birth
4. Street *
4.
*
Street
5. City *
5.
*
City
6. State *
6.
*
State
7. Zip *
7.
*
Zip
8. Best Phone *
8.
*
Best Phone
9. Can we leave voice mail messages and texts? *
9.
*
Can we leave voice mail messages and texts?
Yes
No
10. Email
(By giving us an email address here, you are consenting to receiving email communications from us. This will include email reminders of your appointments and other notices.) *
10.
*
Email
(By giving us an email address here, you are consenting to receiving email communications from us. This will include email reminders of your appointments and other notices.)
11. Gender *
11.
*
Gender
Male
Female
12. Marital Status *
12.
*
Marital Status
Married
Single
Other
13. Employment Status *
13.
*
Employment Status
Employed
Full time student
Part time student
Unemployed/other
14. Brief description of why you are seeking our services (e.g., anxiety, work stress, depression, marital problems, etc.)
*
14.
*
Brief description of why you are seeking our services (e.g., anxiety, work stress, depression, marital problems, etc.)
15. Let us know if you prefer a particular provider (the provider you select might not be available due to several factors such as your insurance company and the provider's available appointment times). You can read our providers' bios at the Clinical Staff page.
15.
Let us know if you prefer a particular provider (the provider you select might not be available due to several factors such as your insurance company and the provider's available appointment times). You can read our providers' bios at the Clinical Staff page.
If you want us to notify your primary care doctor, please provide the doctor's name and fax number:
16. Your Primary Care Doctor's Name
16.
Your Primary Care Doctor's Name
17. Fax
17.
Fax
If client is under 16, please provide the following:
18. Parent/Guardian Name
18.
Parent/Guardian Name
19. Relationship to Client
19.
Relationship to Client
20. Best Phone
20.
Best Phone
Health Insurance Information. Needed in order to process claims. If you are not using insurance, check box 21 and skip to #40. Incomplete or missing information will delay your registration:
21. Check here if you are not using insurance
21.
Check here if you are not using insurance
22. Select your insurance company from the drop down list. These are the ONLY INSURANCES WE ACCEPT: BCBS/Carefirst, Tricare, Johns Hopkins, Cigna, Medicare. Please indicate your PRIMARY insurance only. We do not send claims to SECONDARY insurance companies.
22.
Select your insurance company from the drop down list. These are the ONLY INSURANCES WE ACCEPT: BCBS/Carefirst, Tricare, Johns Hopkins, Cigna, Medicare. Please indicate your PRIMARY insurance only. We do not send claims to SECONDARY insurance companies.
BCBS/CareFirst
Cigna
Johns Hopkins USFHP
Medicare
Tricare
23. Member ID Number (include all letters and numbers)
23.
Member ID Number (include all letters and numbers)
24. Member Group Number
24.
Member Group Number
25. If FEP, Enrollment Code
25.
If FEP, Enrollment Code
26. What is the phone number for "provider services" or "member services" on the back of your insurance card? This may also say "fund office" if your insurance is through a union.
26.
What is the phone number for "provider services" or "member services" on the back of your insurance card? This may also say "fund office" if your insurance is through a union.
27. If using Tricare or Johns Hopkins insurance, they require your full 9-digit social security number.
27.
If using Tricare or Johns Hopkins insurance, they require your full 9-digit social security number.
28. If you have Tricare insurance and are referred to us by a military facility, we are required to share your records with them. Check the box to indicate your consent for us to do so. Unfortunately, we cannot provide you services without your consent.
28.
If you have Tricare insurance and are referred to us by a military facility, we are required to share your records with them. Check the box to indicate your consent for us to do so. Unfortunately, we cannot provide you services without your consent.
29. If Medicare, please provide policy holder's social security number.
29.
If Medicare, please provide policy holder's social security number.
30. If Medicare is primary and you have secondary insurance coverage, please provide: Secondary Insurance Name, ID Number, Group Number, and Policy Holder.
30.
If Medicare is primary and you have secondary insurance coverage, please provide: Secondary Insurance Name, ID Number, Group Number, and Policy Holder.
31. Policy Holder's Employer
31.
Policy Holder's Employer
If client is not the policy holder:
32. Relationship to Policy Holder
32.
Relationship to Policy Holder
Child
Spouse
Grandchild
Legal Guardian
Other
33. Policy Holder's Name
33.
Policy Holder's Name
34. Policy Holder Gender
34.
Policy Holder Gender
Male
Female
35. Policy Holder Phone
35.
Policy Holder Phone
36. Policy Holder Date of Birth
36.
Policy Holder Date of Birth
37. Street (if different from client)
37.
Street (if different from client)
38. City
38.
City
39. State
39.
State
40. Zip
40.
Zip
Client-Provider Agreement:
41. Check this box to electronically sign the Client-Provider Agreement. If client is under 16, a parent or guardian must sign the Agreement.
41.
Check this box to electronically sign the Client-Provider Agreement. If client is under 16, a parent or guardian must sign the Agreement.
42. Name of person(s) completing this form:
42.
Name of person(s) completing this form:
Submit
