Reintegrate Mental Health & Counseling, PLLC

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Administrative

How did you hear about us?

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Payment method

How do you plan to pay?

Answer If using Insurance:

Please call the toll-free number on the back of your insurance card. When prompted, ask for "outpatient mental health benefits" or "behavioral health benefits". Ask the following questions and record them below. 1. Is this provider in my network?, 2. What is my in-network deductible? amount met & co-pay, 3. What is my out-of-network deductible? amount met & co-pay, 4. Maximum out-of-pocket/stop loss amount per year: ______, 5. Maximum number of sessions per year:, 6. Is Prior authorization required? If so, how is that obtained? ; PRIMARY INSURANCE INFORMATION - Please Answer All Questions. Name of Policy holder: DOB: Gender: Relationship to Patient: Name of Insurance Company: Phone #, Insurance Policy #, Group #, Is this through employer? If yes, provide name of employer

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Preferred modality

In-person Telehealth

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.