New Client Request Form 
At this time Andrea only offers in-person only in the State of Georgia and Telehealth services for GA and WA. She is accepting new clients for individual and couples therapy. 
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Welcome to CAGE Counseling 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. 
Today's Date: *
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Will this inquiry be for you or are you making a referral for someone else?

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Client First Name

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Client Last Name *
Name of Parent or Guardian if applicable
Mailing Address of Client (include City/State/Zip Code)
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Client email address if 16 years old or older (if under 16 years of age please provide Parent/Guardian email address)
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email is required for services, as we are completely electronic and send consents and appointment reminders via email
Client Gender
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Client Date of Birth
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Client 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? *
Required
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. *
Andrea provides 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, she 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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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
Andrea has availability Monday-Friday: Please list what day(s)/times between 5-7pm that works best for you. 
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 (Clinical Director) will coordinate my initial appointment after I have completed the required intake forms.  Please consent to the following ways for communication with you. 
Required
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.

Andrea currently accepts Anthem, Aetna, Cigna, Oscar, United/Optum/UMR and Tricare East. IT IS YOUR RESPONSIBILITY TO ENSURE ANDREA IS IN-NETWORK WITH YOUR INSURANCE BEFORE YOU START SERVICES OR YOU WILL BE RESPONSIBLE FOR THE FULL PAYMENT. ANY COST ESTIMATES PROVIDED ARE NON-BINDING AND SUBJECT TO CHANGE ONCE CLAIMS HAVE PROCESSED.
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 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?
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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. This email will come from CAGE Counseling Services, LLC and will include all of the required intake and consent forms along with copies of your insurance card and a credit card placed on file. 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. We will schedule an initial appointment ONLY AFTER your intake paperwork, consents, and card placed on file is completed. 

2.) If using insurance, we cannot accept cash for insurance clients. You are also agreeing that you understand any cost estimates provided are non-binding and subject to change once claims have been processed.

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. 

Required
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
I agree that CAGE Counseling 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. *
By providing your phone number, you agree to receive text messages from CAGE Counseling Services. Message and data rates may apply. Message frequency varies. Reply STOP to opt out.
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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