APPOINTMENT REQUEST FORM

BREAKTHROUGH THERAPY SOLUTIONS, LLC

848-373-8444

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

NAME (potentail client)

DATE OF BIRTH

BEST CONTACT PHONE NUMBER

Email address

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.

If selected 'yes', please provide mobile number for texts

We are currently only providing services via telehealth. Please select all that apply from below: Looking to offer in-person in 2025. Updates will be provided.

Yes, telehealth is preferred

Yes, telehealth is acceptable, please notify me when in-person becomes available

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

What has led you to contact us today?

symptoms, concerns, goals

Please provide details about your preferences here:

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.

HOW DID YOU HEAR ABOUT US?

Google/Internet search

My insurance company's website

Psychology Today Profile

Referred by doctor or other professional (please specify below)

Referred by family or friend

Our website (www.btstherapy.com)

Another directory (please specify below)

Other (please specify below)

PLEASE SPECIFY DETAILS FROM ABOVE, IF APPLICABLE:

INSURANCE AND PAYMENT INFORMATION

HOW DO YOU PLAN ON PAYING FOR SERVICES? (select all that apply)

Not using insurance. I plan to pay for services myself, out of pocket

Use Insurance to pay for all or some of the costs

I have an HSA, FSA or other benefit I plan on using

Unsure

Insurance Information

I am the primary policy holder I am a dependent covered by the policy N/A-I'm not using insurance

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

(example: name of insurance plan)

More details about Insurance (if applicable) (example: secondary plan, plan not listed in options)

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

Insurance Company and Plan Name

example: BCBS NJ Direct, BCBS, United, UHC, 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 for 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

Date

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.