APPOINTMENT REQUEST FORM

background information, demographic information, insurance/payment option information

Please correct the errors described below.

Appointment Request Form

Thank you for considering Breakthrough Therapy Solutions (BTS) to help you on your journey to improved mental health. We try to respond to all requests immediately but no longer than 1 business day.

Important Notes:

  • This is a pre-screening form, not a guarantee of services or a contract.
  • The information provided will help us decide if BTS can support your needs or if a referral to another provider is necessary.

Crisis Notice:
If you or someone you know is experiencing thoughts of suicide, self-harm, harm to others, or safety concerns, call 911 or contact your local emergency services. For Ocean County Psychiatric Emergency Screening Services (PESS), call (732) 886-4474 or 1-866-904-4474.

This form is for non-crisis outpatient services only. Please use the resources above for immediate assistance.

Once your form is reviewed, we will contact you with the next steps in the process.


Basic Info & Contact Info

TEXT COMMUNICATION CONSENT

We understand that text messages can be a quicker and more convenient way to communicate and many people prefer this method. However, text communication is not fully secure and may pose risks to your privacy.

By consenting (selecting yes in the drop down box below), you acknowledge and accept these risks and agree to receive texts for the sole purpose of confirming receipt of this form and providing updates about next steps. Any detailed communication or follow-up will be sent securely via email.

If you do NOT consent, you may select 'No' in the next box.

specify days, times, etc
symptoms, concerns, goals
We cannot guarantee we'll be able to accommodate but we will do our best to match you with a Clinician that suits your stated preferences.

INSURANCE AND PAYMENT INFORMATION

(example: name of insurance plan)

INSURANCE POLICY INFORMATION (You may skip this section if you are NOT using insurance)

example: BCBS NJ Direct, BCBS, United, UHC, Omnia, Cigna, Aetna Choice Plus, etc)
If you are the policy holder, enter your name here
(required for claims)

CERTIFICATION AND SIGNATURE

type name

Thank you for taking the time to complete this form. Upon submission, a member of our team will review your information and contact you. Although we try to contact within the same business day, please allow up to 1 business day for a response. We look forward to speaking with you and discussing the next steps in this process.

Your information will be encrypted.

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