Next Appointment Request [RC]

Next Appointment Request

Please complete this form to schedule your next appointment or follow-up visit.
Scheduling for the first time? Get started with our new client form.

Please Note: Our scheduling staff respond to inquiries during business hours only.
Are you the client?*
Name of Requester*

First NameLast Name
Relationship to Client*
Provider, Caregiver, Teacher, Guidance Counselor, etc.
Requesting Organization*
Hospital, Facility, School, Independent Clinic, etc. –– if you are a Caregiver, Parent, etc., please write "N/A" here.
Requester's Email*
Please enter your email address where we can contact you regarding this appointment request, as needed.
Client Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Mobile Number*
Does the client agree to receive SMS messages at the phone number listed above?

Yes, client agrees.
By checking this box, you consent to receive text messages from Responsive Centers regarding your inquiries, orders, or services. You may opt-out at any time by replying STOP. For assistance, text HELP or review our Privacy Policy: https://responsivecenters.com/privacy-policy.php. Message and data rates may apply. Messaging frequency may vary. By checking this box, you acknowledge that you have read and understood our Privacy Policy and the terms and conditions written here. For better communication, scheduling, and completing paperwork, we recommend clients consent to receiving text messages from Responsive Centers.
Scheduling Information

Please select your availability for efficient scheduling. Evening and weekend requests are considered special requests and will be accommodated according to the clinician's schedule.
Clinician Name*
Client's Availability
Preferred Time of Day

Morning [8 to 11]Lunch Hour [11 to 1]Afternoon [1 to 5]Evening [After 5]Other
Would you like to add any other information?
Billing Information
Would you like to make an update to payment type or insurance details?*

No, I don't have any updates.Yes, I would like to update it now.Yes, please contact me for updates before my visit.
Payment Type*
Choose Insurance or Self-Pay
Insurance Provider*
Other Provider*
If selected 'Other', include the name of the Client's Insurance Provider
Member ID/EAP Auth. #*
Policy Holder's Relationship to Client*
Policy Holder's Gender*
Insurance Card (Front)
Insurance Card (Back)
HIPAA Acknowledgement

Clients have certain rights to privacy regarding their protected health information under the HIPAA Act. By checking the box above and submitting this form, the client is acknowledging that they may voluntarily be sharing sensitive information with our practice. While Responsive Centers cannot guarantee confidentially, we will never share any sensitive information with unknown third-party entities or use it for purposes outside of intake and scheduling. Please review our complete Privacy Policy here: https://responsivecenters.com/privacy-policy.php.
Date

MonthDayYear
Today's Date
Signature

Clear
Should be Empty:

Next Appointment Request

Client Information

Scheduling Information

Billing Information

HIPAA Acknowledgement