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BREAKTHROUGH THERAPY SOLUTIONS, LLC

848-373-8444

CONTACT INFO AND PREFERENCES

NAME (potentail client)

DATE OF BIRTH

BEST CONTACT PHONE NUMBER

Email address

ACCEPTABLE METHOD OF INITIAL CONTACT select all that apply

Text

Phone Call

OPTIONAL (ADD MORE DETAILS)

PREFERENCES AND AVAILABILITY

What days/times usually work best for you? (select all that apply-add optional details below)

Weekday mornings (8am-12pm)

Weekday afternoons (12pm-5pm)

Weekday evenings (after 5pm)

Weekends

Flexible

My availability varies

Do you have any requests or preferences? (optional)

If you'd like to give more specific details about your availability, please provide that information here:

specify days, times, etc

LOOKING TO USE INSURANCE?

Select One

YES

UNSURE

OPTIONAL--TO SPEED UP INSURANCE VERIFICATION PROCESS

Complete the boxes below and have your insurance verified so you know if we are in network and if you have any out of pocket costs. If you prefer to wait and provide that information later, you may skip this section.

Full Name of Policyholder

(primary individual on policy)

Policy Holder Date of Birth

Member ID #

CERTIFICATION AND SIGNATURE

By typing my name and date in the boxes below, I am certifying that all information I have completed on this form is accurate to the best of my knowledge

type name

Date

Thank you for taking the time to complete this form. A member of the Breakthrough Therapy Solutions team will be in touch with you shortly to follow up about the next step in the scheduling process. We aim to respond within minutes---but we will be in touch with you within one business day.

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