Secure Contact Inquiry Form

Welcome!

Thank you for being here and taking a few moments to provide your information.

By submitting this secure form, you permit Revive Relationship Therapy to verify insurance benefits and to correspond with you by email and phone for the purpose of receiving professional services.

Full Legal Name

Nickname or Preferred Name

Date of Birth: MM/DD/YEAR

Phone Number

If you are seeking couples therapy, please share your partner's information:

Partner's First & Last Names

Partner's Email Address

Needed for partner's consent and intake forms for couples therapy.

Partner's Date of Birth

Partner's Phone Number

Street Address (+Apt/unit) Matching the Insurance Card

City

State

Zip Code

Insurance Co. (or write "Private Pay")

I'm in-network with Aetna, Anthem, BC/BS, Optum/United Healthcare commercial plans, Sentara, and UPMC. I do not participate in Medicare, Advantage Plans, Tricare, or Medicaid.

Member ID on Insurance Card

If you are not the primary subscriber on the insurance, list the following information: Primary Subscriber's Full Name, Date of Birth, and relationship to you (e.g., parent, spouse)

Primary Subscriber's Information

Secondary Insurance and Member ID

If I am unable to bill your secondary insurer, I will provide receipts that you can submit for reimbursement.

Are you using EAP (employee assistance plan) benefits? List EAP company, authorization number, number of sessions, and start and end dates for the authorization period.

I work with Anthem/Carelon Wellbeing EAP only.

Email is required for initial intake forms and administrative communication. If you prefer not to communicate via email, alternative arrangements can be made.

Your information will be encrypted.