New Client Interest Form
At this time our therapists offers in-person only in the State of Georgia and Telehealth services for GA, FL, SC. We are accepting new clients for individual and couples therapy. We do not bill insurance for couples therapy.
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Welcome to CAGE Counseling & Consulting Services, LLC
Congratulations on reaching this moment! Taking that initial step can be intimidating, and navigating our world might seem daunting. But rest assured, you're not alone. We're here to accompany you on your quest to find the perfect provider.

The following questions are designed to assist us in matching you with a therapist and addressing any common inquiries that arise during our intake process. If anything is unclear, don't hesitate to ask at the end. Take a deep breath – you're capable of this! Let's infuse a bit of enjoyment into the journey. 
Insurance:
We are NOT currently accepting EAP, Medicaid, or Medicare program clients at this time. In Georgia, if you have Medicaid/Medicare, we must first direct you to a provider who accepts Medicaid/Medicare like the local community service board or another local private practice provider, and if you still wish to proceed with us at our private pay rate you may do so. Please contact us regarding our rate as we offer competitive self-pay rates, and we can discuss a reduced rate if you have a financial hardship. We may require proof of financial hardship.

We ARE in network with commercial plans of Anthem, Aetna, Cigna, Oscar, United/Optum/UMR but you must be a Georgia resident. We also accept Healthgram, Care Network, Tricare East, and Memorial Health Partners. IT IS YOUR RESPONSIBILITY TO ENSURE ONE OF OUR PROVIDERS ARE IN-NETWORK WITH YOUR INSURANCE BEFORE YOU START SERVICES OR YOU WILL BE RESPONSIBLE FOR THE FULL PAYMENT.
Will this inquiry be for you or are you making a referral for someone else?

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Patient First Name

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Patient Last Name *
Name of Parent or Guardian if applicable
Mailing Address of Patient (include City/State/Zip Code)
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Patient email address if 16 years old or older or Parent/Guardian email address
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Patient Gender
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Patient Date of Birth
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Patient phone number if 18 years old or older or Parent/Guardian phone number
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Which services are you seeking at this time? *
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Skip this question if the client is over 18. If the child’s parents are not married, we will need a copy of a custody agreement and may need consent forms signed by both parents if legal custody is shared. We can discuss your situation further if you have questions. *
Our therapists provide sessions through both Telehealth (video) and in-person formats, depending on availability. How would you prefer to connect? (If you are within a 30 mile radius of Effingham County, we only offer in-person sessions at this time and Telehealth services may not be suitable for clients currently experiencing or with a history of crises due to the nature of remote support.)
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Do you have a preference on therapist assigned? If so, please select who you prefer to be seen by. *
If you are unsure, please visit https://www.cagecounseling.com/about-us/our-therapists to read our therapists bio. 
Select all possible times you are available for sessions (check all that apply). Note: After school hours are available in a limited capacity and may delay the beginning of treatment. *
Required
Privacy and Security: *
I understand that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email can be intercepted and read by other parties beside the person whom it is addressed. I also understand that Scarlet Chancey will coordinate my initial appointment after I have completed the required intake forms. I give her permission to leave me a message at the phone number and email address provided. 
Required
If you will be using insurance, what type(s) of insurance do you have? Below is a list of insurances currently accepted or billed at CAGE Counseling and Consulting Services, LLC. One of these plans MUST be your primary insurance as we do not accept secondary insurance plans at this time. If you are using Anthem/BCBS you must physically be located in the State of Georgia, we cannot bill Telehealth services outside of Georgia for that plan. 
WE ARE NOT ACCEPTING NEW MEDICAID/MEDICARE/EAP CLIENTS AT THIS TIME.
*Note: there may be a waitlist for insurance-based clients due to high demand.
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If you have a private or commercial insurance policy, what is your Member ID?
Please note, if you do not provide the required information to verify benefits, this can delay starting services. 
If you have a private or commercial policy, what is your group number?
Please note, if you do not provide the required information to verify benefits, this can delay starting services. 
Name of the policy holder and DOB (often this is a parent or spouse for commercial policies).
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Please note, if you do not provide the required information to verify benefits, this can delay starting services. 
Do you have a secondary Insurance?
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Please note we do not accept secondary insurance plans at this time
Was your assessment prompted or suggested by the criminal justice system?
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If you selected yes to the above question, please provide more details
Has your family ever been involved or currently involved with the Department of Family and Children Services (DFCS)?
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If you selected yes to the question above, please provide more details
What are the primary concern that you are seeking services for?
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Required
If you selected other, please tell us why you are seeking counseling services at this time.
How did you learn about our practice?
Next Steps:  *

Here are the next steps:

1.) All new clients: Once your insurance is verified (we kindly ask that you give us three business days) then you will need to complete your Sessions Health portal profile. Be sure to familiarize yourself with our late cancel/no show policy in our Consent for Services. We will email this form to you with the intake paperwork within three business days or you may find out late cancel/no show policy listed on our website under Billing & Insurance/Practice Policies. We require a card placed on file in your portal profile to receive services. 

2.) If using insurance, depending on your insurance carrier you will have to complete an Alma (Aetna, Cigna, Oscar, Optum/United Health/UMR) or Headway (BSBS only) account. Have your insurance card handy. They will require a debit/credit card on file for copays/no shows. You will be required to have a card on file both in Alma/Headway and your portal profile. We cannot accept cash for insurance clients.

3.) For private pay, we require a $50 intake deposit upon scheduling to encourage intake attendance. This fee reduces the amount due at time of intake instead of the full fee based upon your therapist. If you are on a reduced rate you will pay the remainder of the balance at the time of your intake but the initial $50 is still required. Future session fees are due at the time of treatment. We require a card kept on file to charge the day of services. 

We do require paperwork to completed within 3 business days of sending it and prior to scheduling an appointment. Our therapists are only in the office when seeing clients, so we try to be respectful of their time.

Required
I agree that CAGE Counseling and Consulting Services, LLC., may receive the information above electronically and may communicate with me. I understand that this form is not a guarantee of services. I also understand that email transmissions are capable of being intercepted, and privacy of any confidential information that is sent or received cannot be absolutely guaranteed. I agree to the terms, risks, and limits. *
Please select you are aware of the following:  At this time our office is not ADA accessible. To access it, you must be able to navigate one flight of stairs. *
Required
EMERGENCY RESOURCES:  
If you are ever in a state of emergency, call 911 or go to the nearest emergency room. The following local resources are an alternative option for potential clients who find themselves needing a higher level of care. 

National Suicide Prevention Lifeline: 1-800-273-TALK (8255)

Georgia Crisis Access Line: 1-800-715-4225

Suicide & Crisis Lifeline: 988 or chat 988lifeline.org

The Teal House Sexual Assault and Child Advocacy Center: 912-489-6060

CARES Warm Line: Call or Text Every Day Of The Year 1-844-326-5400 8:30AM- 11:00PM


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