REQUEST FOR SERVICES FORM

background information, demographic information, insurance/payment option information

Please correct the errors described below.

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

symptoms, concerns, goals
specify days, times, etc

INSURANCE AND PAYMENT INFORMATION

(example: name of insurance plan)

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.

example: BCBS NJ Direct, BCBS, Omnia, Cigna, Aetna Choice Plus, etc)
If you are the policy holder, enter your name here
(required for claims)

CERTIFICATION AND SIGNATURE

type name and date

Your information will be encrypted.

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