New Client Screening Form

Alliance Mental health and Youth Consultation Services, LLC

Please correct the errors described below.

All information provided should be for the potential client.

We do need consent from both parents / guardians to treat a minor. Ideally the provider would prefer to meet with any responsible parties before meeting the potential client. If that isn't possible, consent can be given by email / phone but it does need to be received before they can be seen. It is the responsibility of the parent / guardian initiating contact with us to secure that consent.

Presenting Concerns

Please note that Individual and Family / Relationship counseling cannot be performed by the same provider.

Relationships - Please note that we need each member to complete their own screening form in order to complete the review.

History of Treatment

Symptoms

Please note that we do not have anyone on staff that is trained to treat substance abuse, addiction or eating disorders. If any of these is a concern, we may not be a good fit.

If you think there is a possibility that you will want to continue seeing the provider after your Lyra covered visits have been exhausted, please provide your insurance information here so we can verify it in advance. If you'd prefer to be discharged at the end of your Lyra coverage, you can select that option under "Primary Insurance Company" below.

    Please upload a file
    We have providers in network with Anthem / Blue Cross, Medicare, Martin's Point, and Ambetter. Any other carrier would be out of network.

    Please note that if we are not in network with your insurance you will be charged for services on the day of each session. We are happy to provide documentation if you decide to seek reimbursal from your insurance.

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