New Client Appointment Request - Secure Portal - By entering your full name, email address, insurance information and phone number below, you are providing personal information that will be used by Master Peace Wellness & Consulting, PLLC for the sole purpose of responding to your request. We will only use this information to contact you to schedule your appointment.

If you are in serious or foreseeable danger, please call 911 or go to the nearest hospital.

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

Client Info

Therapy For:

Adult Individual Minor

Under age 18; add parent/guardian info in next section

Couple

Add partner info in next section

Client First Name

Client Last Name

Client DOB

XX/XX/XXXX

Gender

Please provide gender on file with insurance.

Phone

Home Address

Apt #

City

State

Zip Code

Parent/Guardian/Partner Info (This section is required for Minors and Couples Counseling only)

Parent/Guardian/Partner First Name

Parent/Guardian/Partner Last Name

Parent/Guardian/Partner DOB

XX/XX/XXXX

Parent/Guardian/Partner Gender

Parent/Guardian/Partner Email

Parent/Guardian/Partner Phone

Insurance Info

Insurance Provider Phone #

Insurance Member ID #

Required if using insurance

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. This section is not required for completion.

If no, please provide the Primary Insured information. This information is required to process insurance claims.

Primary Insured First name

Primary Insured Last Name

Primary Insured DOB

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 Information - If using EAP, please complete in entirety.

EAP Insurance Company

EAP Authorization #

EAP validation dates

Start and End dates needed

# of EAP sessions authorized

required for EAP

Upload Insurance card/EAP authorization information

Please upload front and back photo of insurance card and/or EAP Authorization Form. This is needed to verify benefits. Or email documents to info@masterpeacewellness.org

Add file

Please upload a file

Reason for Visit

If you are planning to request document completion for FMLA, Short/Long Term Disability, Accommodations, etc., please provide details

Please note: This information is helpful during the intake process, because not all Providers will complete certain documentation.

Availability for sessions Can choose more than one

Morning

Afternoon

Evening

Best Contact Method Can choose more than one

Text

Call

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 full self-pay rate for individual, couples, family, or group sessions. Rate can be found on our website https://masterpeacewellness.org

Your information will be encrypted.

Master Peace Wellness & Consulting, PLLC

Master Peace Wellness & Consulting, PLLC has a team of licensed mental health professionals providing counseling services for individuals, couples, and families all ages. Our mission is to assist clients with development of greater self-awareness and fulfillment that lead to increased confidence, independence, and wellness.