Health Insurance Contact Form Living Water Counseling Ministry

Client First name

Client Last name

Client Gender

Email

Do you have an active Medicare Policy?

Yes

No

Do you have an active Medicaid Policy?

Yes

No

Counselor does not accept NC Medicaid

Are there any certain days or times you would need services due to other obligations?

Current appointment times are Monday, Wednesday, and Thursday 10:00 am-5:30 pm. I am closed Tuesday, Friday, Saturday, and Sunday.

What issues/problems were you wanting to address in counseling services?

Example: Anxiety, Depression, Grief/Loss, etc.

Have you ever been diagnosed or taken medication for a Mental Health Disorder? If so, what were you diagnosed with or taking medication for?

Example: Depression, Anxiety, Panic Attacks, Bipolar, etc.

Do you have any legal issues I need to be aware of?

Your Full Name on Your Insurance Card

Date of Birth

Month

Day

Year

Your Street Address, City, State, Zip Code

Counselor is only licensed to provide counseling services in Virginia and North Carolina

Name of Insurance Provider

Member ID Number

Phone Number to Provider Services (or Behavioral Health)

Located on the back of your insurance card

Full Name of Primary Insurance Holder

If someone other than yourself

Primary Insurance Holder---Date of Birth and Home Address

If someone other than yourself

Message- If you have a secondary insurance policy please list the name of the policy and ID number here. Also if you want to use your EAP (Employee Assistance Program) Benefits please include the Authorization number and number of sessions here.

Please be aware that all counseling sessions are by Telehealth Only. You will need access to the Internet, your own phone for counselor to get in touch with you in case of technical difficulties during the session, and your own email address where you can receive appointment reminders and document requests. Please be aware that not all issues/problems are appropriate for Telehealth counseling sessions. If at any time counselor feels you would benefit more from In-Person Counseling sessions you will be given a list of other providers in your area.