New form

Due to uncertain times, we are only providing telehealth services at this time.

I agree I am not in danger at this time and would like to request an appointment.

Client Information

Client's First Name

Client's Last Name

Client's D.O.B

XX/XX/XXXX

Gender

Phone

Home Address

Apt #

City

State

Zip Code

Partner's Info (This section is for Couples Counseling Only)

Client's First Name

Client's Last Name

Client's D.O.B

XX/XX/XXXX

Gender

Phone

Formatted

Insurance Information

Insurance Provider Phone #

Insurance Member ID #

Insurance Group #

Billing Address

Your address on file with insurance provider

Apt #

City

State

Zip Code

Primary Insured Information

Are you the Subscriber for the insurance policy? If the client is not the holder of insurance policy, the Primary Insured information is needed for insurance purposes

Yes

If yes, please go to next section

Primary Insured First Name

Primary Insured Last Name

Primary Insured D.O.B

Primary Insured Gender

Primary Insured Phone Number

Primary Insured Relationship to Client

Primary Insured Billing Address

Address, City, State, Zip Code. On file with insurance company

EAP Appointment Request

EAP Company Name

EAP Pre-Authorization #

For EAP appointment request only

EAP effective dates

# of EAP sessions authorized

Please upload front and back photo of insurance card and/or EAP Authorization Form. Or email documents to info@guidinglightcounselinggroup.org

Add file

Please upload a file

Reason for Visit

Availability for sessions

Morning

Afternoon

Evening

Checkbox

I understand there is a fee associated with no show or late cancellations. We ask you to inform us at least 24 hours in advance if you are unable to make a scheduled appt or you will be charged a fee of $130/individual or $150/couples-family (with fully licensed staff) or self pay rate with Associate or Grad Intern.

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