Couch Clarity Intake
Intake Information.  Please complete (takes approx 3 minutes) and make sure to press the "Submit" button at the end.  Thank you!
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Email *
Name of Client (First and Last Name)
 *
Birthdate of Client
 *
MM
/
DD
/
YYYY
If you are not the client, please type your NAME and RELATIONSHIP to client:
Name of Therapist (if you have a preference):
*You can find Therapist Bios at couchclarity.com
             
(Our Intake Scheduler can also assist you)
What location do you prefer?
Clear selection
Availability for Therapy (check all that apply)
 *
Required
Phone Number of Person to Contact for Scheduling
 *
Brief Reason for Seeking Therapy
 *
If you are scheduling for a minor/child:
 *
Please select #1 or #2:
1. I want to schedule an appointment with the understanding that I am responsible for knowing my eligibility and benefits. 
2. I will check the eligibility and benefits with my insurance provider and call back to schedule an appointment (instructions are at the end of this form).
*
How did you hear about us?
 *
What type of insurance do you have?

Please note Couch Clarity is a BCBS PPO provider for most BCBS plans as well as Blue Choice.  We are considered out of network for all other plans.  According to insurance providers, members are contractually obligated to know their benefits.  We advise contacting your insurance company’s Member Services to receive your explanation of benefits.

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