START HERE: New Client Inquiry & Information Request Form

BREAKTHROUGH THERAPY SOLUTIONS, LLC

848-373-8444

CONTACT INFO AND PREFERENCES

NAME

BEST CONTACT PHONE NUMBER

Email address

Please Note

Due to the nature of the practice, our initial response to this request will be via email (usually within an hour, but no longer than one business day). Should a phone call be necessary during the setup process, arrangements can be made.

DATE OF BIRTH

for person seeking services)

A) Name and DOB of person or persons who will be receiving the services:

Please provide referral source (optional)

This helps us to keep track of referral sources

B) Please provide a brief explanation of the type of services you're looking for and what brings you to Breakthrough Therapy Solutions?

PREFERENCES AND AVAILABILITY

For each day, please provide your earliest possible start time. you can also add specific details, a range of time or say N/A. This will significantly help speed up the process.

Mondays:

Tuesdays:

Wednesdays:

Thursdays

Fridays

Saturdays

Sundays

Client preference for session type/format: Please select from the options below, regarding your thoughts on virtual/telehealth sessions if in-person not available

Yes, that's my preference

Yes-I'm comfortable with telehealth/virtual

I prefer in person but ok with telehealth/virtual if that's the only option

No-Telehealth will not work for me

Please add any notes or information about scheduling that you'd like us to know.

LOOKING TO USE INSURANCE?

**If you are NOT using insurance, only the first question in this section is required and you may skip to the next section**

Do you have insurance

YES I have insurance

YES-But I prefer to self-pay and opt out of using my insurance.

NO INSURANCE- (I will be SELF PAY)

UNSURE

Name of INSURANCE plan NOT LISTED IN PRIOR DROP DOWN MENU

If you have secondary insurance, please provide insurance plan name, policy number, name and DOB of policy holder

PLEASE PROVIDE INSURANCE DETAILS AND WE WILL ATTEMPT TO VERIFY YOUR INSURANCE COVERAGE

PRIMARY INSURANCE INFORMATION

Primary Policy Holder Full Name:

POLICY HOLDER EMPLOYER

Member ID #

PRIMARY POLICY HOLDER DOB

SECONDARY INSURANCE INFORMATION (if applicable)

CERTIFICATION AND SIGNATURE

By typing my name below, I'm certifying that everything in 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 process. Estimated response time: 1 hour but no longer than the next business day.

LOOKING FOR MORE INFORMATION WHILE YOU WAIT TO HEAR FROM US?

Check out our website, including FAQ's, therapist profiles and much more.

Go to www.btstherapy.com

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