Please complete this section if you have Medicare, Tricare, Blue Shield Magellan health insurance OR if you would like us to check your out of network benefits.
Insurance carrier name
Member ID #
What is your date of birth? (we use this information to check your benefits)
Name and date of birth of primary subscriber
What are you currently struggling with? *
What are your goal(s) for therapy? *
Have you ever experienced thoughts of wanting to hurt/kill yourself or someone else? *
Have you ever had any suicide or homicide attempts? *
Have you been previously diagnosed with a mental health condition by a professional? If yes, please list all previous diagnoses *
Is this your first time in therapy? *
Please let us know if you know which therapist that you would like to work with. Therapist bios can be found on our website at www.aspireneuropsych.com
Is there anything else that you would like us to know?
Please note that our therapists are not crisis counselors. We encourage all clients to call 911 or go to their nearest emergency room if you are having a mental health crisis. Thank you for your time, we will be in touch shortly.
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