REQUEST FOR SERVICES FORM

BREAKTHROUGH THERAPY SOLUTIONS, LLC

848-373-8444

PURPOSE OF THIS FORM

This screening form is designed to help BTS gather important initial background information to determine if services can be provided by one of the Counselors on the BTS team. Please note that this is only a pre-screening form and is not a guarantee of services nor a contract of any kind. The information that you provide will help BTS understand what you are looking for regarding therapeutic services. In addition, the information that you provide will help BTS determine if services can be provided or if a referral is more appropriate. This form has questions regarding basic background information, demographic information and insurance/payment option information.

Once this form is submitted and reviewed by BTS, you will be contacted with more information regarding next steps.

**Important** If you or anyone you know is currently experiencing thoughts of suicide, self-harm, thoughts of harming others or are fearful for your own safety or the safety of anyone else, please immediately call 911 and/or your local psychiatric emergency services phone number for immediate assistance. There are professionals who will assist you if you call. The phone number for Ocean County Psychiatric Emergency Screening Services (PESS) is (732) 886-4474 or 1-866-904-4474. If you are not in Ocean County, you may call 911 for your local emergency services contact information.

**Only complete this form if you are not experiencing a crisis or emergency. This is only a pre-screening form for outpatient services and is not designed to provide immediate assistance for emergency situations.

DEMOGRAPHIC AND BACKGROUND INFORMATION

NAME OF POTENTIAL CLIENT

DATE OF BIRTH (for potential client)

BEST CONTACT PHONE NUMBER

EMAIL ADDRESS

Please give a brief description of what has led you to seek services at Breakthrough Therapy Solutions, LLC

symptoms, presenting concerns, etc.

We are currently only seeing clients via telehealth (video or phone). Please select all that apply from below:

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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