Access For Change, LLC Request For Services

Access For Change,LLC

Service request Form
Thank you for your request. Currently, Access for Change is accepting referrals on an extremely limited basis due to capacity limitations. We will do our best to get back to you in a timely manner should an opening become available. Given these constraints, we encourage you to consider seeking help from other providers to ensure you receive the support you need more immediately. We appreciate your understanding and patience.
Best regards,
The Access for Change Team
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Preferred Method of Contact*

Cell PhoneHome Phone
Cell Phone*
Home Phone
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*
Employment*
Why you are seeking treatment?*
Were you referred to a specific therapist? If yes please identify from list
Why Are you seeking treatment*
primary Care
Referral Name

First NameLast Name
Emergency Contact Information
Name of Emergency Contact *

First NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship To Emergency Contact *
Are You Using Health Insurance ?*

YesNo
If yes, what is your Primary Health Insurance ?
Do you have a secondary Health Insurance Plan? If yes Please list.
If you are using insurance,

call our billing office.

at 800-946-1101.

Once we receive your Insurance Information, we wil contact you.
Medical History
Please check all the apply*

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
Caffeine use?

NoDailyWeeklyLessFormer User
Do you use tobacco?*

NoDailyWeeklyLessFormer User
Do you use alcohol?*

NoDailyWeeklyLessFormer User
Are you currently taking prescription medication?*

YesNo
If taking medication prescriber Name & Number

First NameLast Name
Medication Provider
Have you had any surgeries in the past 5 years?

YesNo
Please specify:
Family history*

AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal DiseaseOther
What type of Service are you requesting*
Mental Health History
Therapist Name

First NameLast Name
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?*

YesNoOther
Average hours of sleep per night
Please describe any other experiences you have had problems with
What do you expect from this counselling?*
Are you requesting ?*

In office appointmentsVirtural appointmentsCombination of in office and virtual appointments
Additional comments or concerns
Please verify that you are human*
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Access For Change,LLC

Emergency Contact Information

Medical History

Mental Health History