Request Information/Appointment Patient Full Name(required) Date of Birth(required) Full Physical Address(required) Best Contact Number(required) Email Address(required) Other Participant Full Name and DOB (Guardian if minor, Spouse if Marital Therapy) Insurance Company(required) Aetna Aetna EAP Anthem BCBS AllHealth EAP Cigna Cigna EAP Humana Tricare Humana EAP Optum UBH GEHA Optum UBH GEHA EAP Optima Compsych EAP ACI Specialty EAP Magellan EAP Self pay using HSA or Debit/Credit Card Insurance ID#(required) Insurance Group #(required) Authorization # if applicable Number of sessions authorized if applicable Deductible Copayment(required) Subscriber Name(required) Subscriber Date of Birth(required) Subscriber Phone Number(required) Requesting Christian Counseling(required) Yes No Spirituality Customization(required) None Christian/Protestant Catholic Jewish Interfaith * Couples having different faiths Other Telehealth*video counseling requested. This is available for existing patients only Submit Share this:FacebookLinkedInTwitterEmail Leave a Reply Cancel reply Enter your comment here... Fill in your details below or click an icon to log in: Email (required) (Address never made public) Name (required) Website You are commenting using your WordPress.com account. ( Log Out / Change ) You are commenting using your Google account. ( Log Out / Change ) You are commenting using your Twitter account. ( Log Out / Change ) You are commenting using your Facebook account. ( Log Out / Change ) Cancel Connecting to %s Notify me of new comments via email. Notify me of new posts via email.