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Idell Counseling Waiting List
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Client Name
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Your answer
Client Date of Birth
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YYYY
Phone Number
*
Your answer
Email
Your answer
Insurance
*
BlueCross BlueShield
Optum/UnitedHealth Care
Cigna
Tenncare Amerigroup
Tenncare BlueCare
Tenncare UHC
Medicaid Bluecare
Selfpay
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Service Needed
Individual Therapy
Couples Therapy
Family Therapy
Reason for services needed
*
Anxiety
Depression
ADHD
Autism
Bipolar/Mood Disorder
Trauma
Postpartum Depression/Anxiety
Relationship Issues
Family Issues
Substance Use
Other:
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