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BREAKTHROUGH THERAPY SOLUTIONS, LLC

848-373-8444

CONTACT INFO AND PREFERENCES

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BEST CONTACT PHONE NUMBER

Email address

PREFERRED METHOD OF INITIAL CONTACT (select all that apply)

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Phone Call

Note: Calls may take longer for follow-ups

A) Name and DOB of person you're seeking services for if anyone other than yourself:

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B) Questions you have/Information you'd like to share with us

PREFERENCES AND AVAILABILITY

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include your preferences as well as when you're NOT available

LOOKING TO USE INSURANCE?

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IF 'OTHER' INSURANCE (Insurance company and plan name)

OPTIONAL--PROVIDE INSURANCE DETAILS

If you complete this section, we will verify your plan and this will help speed up the process for the next step to get started

Full Name of Policyholder

(primary individual on policy)

Policy Holder Date of Birth

Member ID #

CERTIFICATION AND SIGNATURE

By typing my name below, I'm certifying that everything in this form is accurate to the best of my knowledge.

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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 scheduling process. We aim to respond within minutes---but no later than one 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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