Tele-therapy Consultation Form
Hey there! You should really give yourself a BIG HUG!!! You are taking a big, conscious, and intentional leap towards improving your life, as well as the lives of others you care for, encounter, and/or connect with. YOU WON'T REGRET THIS!!! Please complete the form below. We will contact you with the information provided within 48-72 hours. Have a great day!  **If you are not a NC resident, you CANNOT receive tele-therapy services**
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Email *
Today's date? *
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Parent/guardian name if recipient for services is a minor?  *
Name of recipient receiving services? *
What is your Date of Birth (recipient's DOB)? *
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What is your insurance number?(Member ID #) *
What is the last four of your SSN? *
What is your Address? Please include street, city, state, and zip code of your physical location *
Email *
Phone number *
Are you a recipient of these insurance carriers? *
Please provide a brief summary of what you are seeking services for? *
How did you hear about Youthful Connections? *
Please be aware that if your insurance carrier does not accept tele-therapy services or you do not have an insurance carrier, you will be responsible for payments rendered prior to services? A list of service costs can be located in the 'FAQ' section here https://www.youthfulconnectionspllc.com/faq . Type 'YES' if you understand and accept. *
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