Money Talks Baltimore/Latisha Christensen, LCSW-C Waitlist for 2021
This form is to be completed by the individual seeking counseling and/or treatment services beginning January 4, 2021. Please note: If you are in a crisis it is not appropriate to complete this form. Please contact you referral source to seek out another mental health provider in your network.
Email address *
Full Name *
Email address *
Phone number *
Payment Method *
Select a response. If you the option for EAP, self-pay or the insurance plan option is not applicable, select other. Select all that are applicable.
*For EAP coverage only*
Enter the authorization number, start date/end date and number of approved sessions
*For Insured coverage only *
Enter member ID number, Group number and the phone number on the back of your card for mental health providers. If you are covered by more than one insurance please respond with the primary first, then secondary, tertiary, etc.
Payment for co-pay, co-insurance and deductibles under insurance plans *not applicable for EAP*
This practice accepts credit cards, debit cards, HSA's and payments through PayPal and Cash App. Prior to the initial scheduled appointment, you will receive notice of the estimated payment for services. This is the amount YOU PAY as agreed in the contract with your insurance and collected at the time services are rendered. If the EOB from your insurance shows a difference between what was collected, you will receive a credit OR you will receive an invoice and payment will be due upon receipt. There will be no sessions scheduled until balances owed are settled. Please acknowledge this policy by typing " I agree" below.
Referral Source *
Who can we thank for referring you? Please enter name, telephone number and agency (if applicable). If you were not assisted, please respond "self-referral".
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Money Talks Baltimore LLC. Report Abuse