Art for the Young at Heart Classes

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Participant Email Address *

Todays Date: *

YYYY

Participant Name *

Preferred Name

Participant Date of Birth *

YYYY

Participant Address (Street, City, State)

Zip Code

Participant Phone Number *

It is okay for us to leave a voice mail or to text you at this number? *

Okay to leave text and voice mail.

Okay to leave voicemail only.

What is your session preference? *

How did you find us? *

Name of person completing form if different from the participant.

Relationship to Participant

Phone number of person completing form if different from the participant .

Does the participant have insurance? *

Yes

Insurance Carrier *

Member ID Number (with Alpha Prefix if applicable) for the Insurance Company listed above. Please make sure to enter the information accurately as we will not be able to verify the cost to you and what is covered if we do not have the accurate information. *

Group Number

Policy Holder's Name if Different From Participant

Policy Holder's Date of Birth if Different From Participant

YYYY

Policy Holder's Address if Different From Participant

Do you have mental/behavioral health benefits? *

Yes

If you have a deductible what is the amount of your deductible?

Has your deductible been met for this benefit year? *

Yes

Unknown

No Deductible

What is your copay?

Secondary Insurance

Secondary Insurance Member ID #

What do you hope to achieve from participating in this class? *

Thank you for for submitting your request to participate in The Art for The Young at Heart class.

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