If you are an ADULT, please enter an Emergency Contact or indicate “DECLINED”:

 If the client is a CHILD:  

PARENT/GUARDIAN 1

PARENT/GUARDIAN 2

Insurance

Please input your insurance details fully and accurately!

Please note that our office cannot guarantee acceptance of all insurance plans. Upon receiving your completed intake form, our admin team will verify your insurance details and inform you of coverage eligibility!

Primary Insurance

Insurance Card

Please upload clear photos of the front and back of your insurance card!

Secondary Insurance (Husky secondary or MPB Supplemental Policies only)

Employee Assistance Program (EAP)

If you have EAP sessions provided to you by your employer, please complete this section:

Referrals

Reason for seeking support