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

Phone Number

Street Address (and apartment/unit)

City

State

Zip Code

Date of Birth

Insurance Company (or write "None" for private pay)

Member ID on Insurance Card

Group Number

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

Are you using EAP (employee assistance plan) benefits? List insurer, auth#, and # of sessions.

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.