First Step Toward Better Days Ahead - Emerald Therapy Center

1

Existing Clients* This field is required.If you've met with someone at Emerald within the last 6 months, please call 270.534.5128 to schedule an appointment.

I understand

2

Name* This field is required.

First Name

Last Name

3

Birth Date* This field is required.

4

Gender* This field is required.

5

Guardian's Name(if applicable)

First Name

Last Name

6

Phone Number* This field is required.We will contact you to set up your first appointment. In the future we will send you appointment reminders via text.

Area Code

Phone Number

7

Please Confirm Your Phone Number* This field is required.

Area Code

Phone Number

8

Email* This field is required.

example@example.com

9

Address* This field is required.Please use the address listed on the insurance card (if applicable)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

10

Social Security NumberThis is required to verify benefits for certain insurance carriers. Please skip if you plan to pay as a self-pay client or if you prefer to give this to us over the phone when we reach out to schedule your first appointment.

11

Our Promise: Mental Health Services Cannot Wait.* This field is required.One of our representatives will reach out within 24 business hours to schedule an initial appointment. If unsuccessful, please call 270.534.5128 option #2.

I understand

13

Insurance Carrier:
Policy Holder's Name:   First Name     Last Name
Policy Number:
Group Number:
Group Name:
SSN:    000-00-000

14

Insurance CardPlease upload a copy of your insurance card front and back (if applicable).

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