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Alternative and Holistic Approaches

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Alternative and Holistic Approaches

Holistic methods such as art therapy, yoga, and mindfulness.

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Submit Your Resume

Upload your resume with cover letter stating areas of interest. (population and geographic locations)

First Name(Required)

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Phone

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Email(Required)

Attach your cover letter stating your areas of interest(Required)

Accepted file types: pdf, jpg, doc, docx, Max. file size: 256 MB.

Attach your Resume(Required)

Accepted file types: pdf, jpg, doc, docx, Max. file size: 256 MB.

Intake Form

Step 1 of 3 - Patient Details

33%

Are you currently experiencing thoughts of suicide?

Yes

No

If you’re feeling overwhelmed or struggling with thoughts of suicide, please know that you are not alone. There are people who care about you and want to help. You can reach out to the Suicide & Crisis Lifeline by calling 988 or visiting 988lifeline.org for immediate support. If you are in an emergency, please call 911 or go to the nearest emergency room. Your life is important, and reaching out for help is a strong and courageous step.

Please select a staff member you'd like to meet with.

Patient Details

Patient First Name(Required)

Patient Last Name(Required)

Are You a:(Required)

Minor

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Home Phone

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OK to Leave a Message?

Yes

No

Text

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Patient Speaks

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Patient Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Referred By

Name of Parent or Legal Guardian(Required)

First Last

Insurance Info

Do you have Insurance?

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Social Security #(Required)

ID Number(Required)

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State issued(Required)

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This information is encrypted and protected via SSL (Secure Sockets Layer) a security protocol that creates an encrypted link between a web server and a web browser.

Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Name of Insurance(Required)

Insurance Co. Phone(Required)

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This information is encrypted and protected via SSL (Secure Sockets Layer) a security protocol that creates an encrypted link between a web server and a web browser.

Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Upload photo of insurance card back(Required)

This information is encrypted and protected via SSL (Secure Sockets Layer) a security protocol that creates an encrypted link between a web server and a web browser.

Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Are You In Network?(Required)

Yes

No

Not Sure

Have You Been Seen Yet?

Yes

No

Benefits 1 of 2

Is Provider In Network?

yes

No

Type of Service Requested

Individual

Group

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CASOMB

Type of Appointment Preferred

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Effective Date

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Additional Notes

Example – Do Mental Health Benefits carve out?

Claims Mailing Address

Street Address Address Line 2 City State ZIP Code

Patient Signature(Required)

Parent or Legal Guardian Signature(Required)

Date

MM slash DD slash YYYY