APPOINTMENT REQUEST FORM

BREAKTHROUGH THERAPY SOLUTIONS, LLC

848-373-8444

Appointment Request Form

Welcome! Taking the first step toward therapy is a big decision, and we’re honored you’re considering Breakthrough Therapy Solutions (BTS) to support you on this journey. This form helps us learn more about your needs and determine if one of our Counselors is the right fit to assist you.

Please note: this is a pre-screening form, not a guarantee of services or a contract. The information you provide will help us decide if BTS can offer the services you’re seeking or if a referral to another provider may be more appropriate.

This form collects basic background, demographic, and insurance/payment information to better understand how we can support you. Once submitted and reviewed, BTS will contact you with more information about the next steps. We strive to reply to all submitted requests within 1 business day or less.

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

Only complete this form if you are not experiencing a crisis or emergency. This form is for outpatient services and is not intended for immediate assistance. Please utilize the resources above for assistance.

DEMOGRAPHIC AND BACKGROUND INFORMATION

NAME OF POTENTIAL CLIENT

DATE OF BIRTH (for potential client)

BEST CONTACT PHONE NUMBER

EMAIL ADDRESS

Please tell us what led you to reach out to Breakthrough Therapy Services?

symptoms, concerns, goals

We are currently only seeing clients via telehealth (video or phone). Please select all that apply from below: Looking to offer in-person in early 2025

Yes, telehealth is preferred

Yes, telehealth is acceptable but I'd like in person when it becomes avaialble

Yes, telehealth is acceptable. I have no preference between telehealth and in person

No, telehealth will not work for me

When are you available for telehealth sessions? Select all that apply You can give details in the next box

mornings

afternoons

evenings

I do not want telehealth sessions

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

specify days, times, etc

HOW DID YOU HEAR ABOUT BREAKTHROUGH THERAPY SOLUTIONS, LLC?

Google/Internet search

Psychology Today

My insurance company's website

Referred by doctor or other professional

Referred by family or friend

Breakthrough Therapy Solutions, LLC website

Other

If other, please specify here:

INSURANCE AND PAYMENT INFORMATION

HOW DO YOU PLAN ON PAYING FOR SERVICES?

Pay for services myself, out of pocket

Use Insurance to pay for all or some of the costs

Enter details into next box

Unsure

If you selected "other" in the previous box, please provide details here

(example: name of insurance plan)

If you have more than one insurance plan, please provide details below for which one is primary and which is secondary:

The questions below pertain to your specific insurance policy. Please complete each section. If this does not apply to you, you may type N/A or select the options for N/A in order to complete and submit the form.

Insurance Company and Plan Name

example: BCBS NJ Direct, BCBS, Omnia, Cigna, Aetna Choice Plus, etc)

Name of Policy Holder

If you are the policy holder, enter your name here

Date of Birth of Policy Holder

Member ID #

Group # of Plan

Policy Holder Employer

(required for claims)

If you selected 'Other' in previous box regarding your relationship to the primary policy holder, please provide details here:

Select From the Options Below

I give permission to BTS to verify my insurance information

I do not give permission to BTS to verify my insurance information

N/A, this does not apply to me because I am not using insurance

CERTIFICATION AND SIGNATURE

By typing my name and date in the box below, I am certifying that all information I have completed on this form is accurate to the best of my knowledge and that if any of the information I have provided changes, I am responsible for notifying BTS immediately and in writing.

type name and date

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