Online Intake

First name

Last name

Email

Phone

Have you had therapy before?

Yes

No

What insurance will you be using?

Please enter your insurance ID number for benefit verification. (if not available enter 'n/a')

Are you using EAP benefits

Yes. I have an authorization number

Yes. I do not have an authorization number.

No.

If you have an EAP authorization number, please add it here

What company is your EAP through? (if using EAP benefits)

Is there anything you would like to share about your therapy needs? (not required, just useful to assign a therapist)

Accedence Counseling has updated its No Show and Late Cancellation policy. Please review the policy here: www.accedencecounseling.com/policies

Check the box to indicate you have read and understand the policy. It is the responsibility of our clients to adhere to the policies of the practice.

Thank you for completing this form. We will contact you shortly regarding an appointment.