New Client Interest Form

New Client Interest Form

Thank you for your interest in scheduling an appointment with Sunrise Counseling & Psychological Services!
Confidentiality: The information collected on this form will be used in the client’s best interests to be scheduled to receive psychological/medication services. The information provided will be handled in a professional and confidential manner. Sunrise Counseling holds the disclosure of confidential Information in confidence and will not release any disclosed information to any third party or entity without prior written consent.
Please verify that you are human *

Demographic Information

Tell us about yourself
Client's Name: *

First Name Last Name
Client's Preferred name or nickname:
Client's Date of birth: *

Month Day Year
Date
If you are seeking services on behalf of a minor, please state your name and your relationship:

Requested Services
What services are you interested in? (Choose all that apply) *

Medication Management Therapy Psychological Testing and Assessments Speech Therapy
If you have a request for a specific provider, type of service, or would like to provide any additional details about the services you are requesting, please do so here:

Insurance Information

Please provide your insurance information as this will expedite the intake process.
For your services, do you have insurance or would you be Self-Pay? *

Insurance Self-Pay
Insurance Provider: *
Member ID/Policy Number: *
(For Tricare members, please provide your " Benefits # ")

Need help? The benefits number can be found on the back of your DOD ID in the upper-lefthand corner.
(OR: Upload a photo of your insurance card):

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Additional insurance information:
Additional policy information/details if available:
If you are Tricare Prime with a referral to Sunrise Counseling, Please include your referral information below:

Communication Preferences