Secure Contact Inquiry Form

Welcome!

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

This secure form permits Revive Relationship Therapy to correspond with you by email and phone for the purpose of receiving professional services.

Please complete only Section A if you are simply inquiring about services. I will reach out to answer any questions you may have.

If you are ready to schedule an initial intake appointment, continue with Section B and I will verify your insurance benefits and set up the appointment with you.

SECTION A - Inquiry Only

First Name/Preferred Name

Phone Number

State

How would you prefer to be contacted?

Email Phone

Questions? I'd be happy to answer.

SECTION B - Optional (Complete if you are ready to get started.)

Full Legal Name (Matching Insurance Card)

Date of Birth: MM/DD/YEAR

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

City

Zip Code

Insurance Co. (or write "Self-Pay")

I NO LONGER PARTICIPATE in Tricare, Medicare (original or advantage plans,) or Medicaid. I AM in-network with Aetna, Anthem Blue Cross, Blue Shield, Optum/United Healthcare, and Sentara commercial plans.

Member ID on Insurance Card (or write "Self-Pay")

If I have any difficulty verifying benefits and collecting co-pay information, I will reach out immediately.

Secondary Insurance and Member ID

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

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

If you are seeking couples therapy, I WILL NEED YOUR PARTNER'S EMAIL AND PHONE for intake paperwork including consent forms. Each partner receives a unique link to the confidential client portal for their privacy.

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

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 ONLY PARTICIPATE IN Anthem/Carelon Wellbeing EAP.

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.