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Welcome to Faith and Healing Counseling
Client Information and Insurance Verification Form
  • 1
    Please indicate below how we became known to you or referred.
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  • 2
    Please provide client full name, requesting service
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  • 3
    Please enter client day of birth
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    Pick a Date
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  • 4
    Email address must be verified to continue. A verification code will be sent to this email address. NOTE: Check Spam/Junk folder if not seen in your Inbox.
    Email Verified

    The verification code has been sent to some@email.com
    Please check your mailbox and paste the code below to complete verification

    Didn't receive verification code? or
    Receiving the email may take a few minutes, thank you for your patience!
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  • 5
    Enter your current residential address.
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    • United States
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    • China
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    • Puerto Rico
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    • Republic of the Congo
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    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
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    • Seychelles
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    • Other
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  • 6
    Please provide mobile phone number.
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  • 7
    If mobile and home phone number are the same, select "NO".
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  • 8
    Please provide home phone number.
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  • 9
    Indicated your preferred method to be contacted, if needed.
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  • 10
    Please indicated your current marital status.
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  • 11
    Check each status that applies.
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  • 12
    Please select which method of payment will be used to cover this service.
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  • 13

    Medical Insurance/Employee Assistance Plan (EAP) Eligibility Verification

    Before treatment can begin, as a courtesy, we will contact your insurance company to verify eligibility and determine if prior authorization is needed for treatment. We cannot guarantee that our services will be covered 100% by your insurance. Therefore, we recommend you contact your insurance company directly for details of your specific plan's limitations, exclusions, and benefits.

    To verify your identity and medical insurance eligibility benefits. Please provide a copy of the patient's state-provided driver's license or identification card, medical information ID card for self or the patient's responsible party, or the authorized representative. All information must be current and up-to-date.

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  • 14
    Smartphone/Computer: Take a picture or upload file/image of front and back of Medical ID Card.
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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  • 15
    Please provide client Medical Card ID and Group/Benefit numbers needed for verification.
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  • 16
    Smartphone/Computer: Take a picture or upload file/image of front and back of state-issued Driver License or Identification Card.
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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  • 17
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  • 18
    Clear
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Client Contact and Insurance Verification Form
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