*This question is related to minor clients only--please provide the name, email address, and phone number for each parent/legal guardian
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This question is related to those seeking couples therapy--please provide your partner's name, along with your partner's email address and phone number that can receive emails/calls from Renewal, Growth, & Healing
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This question is related to those seeking family therapy--please provide the full names and ages of those who will be attending sessions with you
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If using insurance, please provide the full name of the person who will be responsible for billing *Please type the name as it appears on the insurance card*
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Renewal, Growth, & Healing emails benefits and scheduling information. We use secure email to send these messages. However, we cannot guarantee the confidentiality of content in a conventional email.
Email address to receive messages from Renewal, Growth, & Healing *
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Phone number to receive calls from Renewal, Growth, & Healing *
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May we leave a voice message at the above phone number? *
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May we send text messages to the above phone number? *
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What is the best way to reach you? *
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Age of person interested in therapy *
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Date of birth of person interested in therapy *
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How did you hear about Renewal, Growth, & Healing?
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A friend/family member
School administrator/Teacher
Psychology Today
A mental health professional
A medical professional
Hospital
Probation Officer
Google
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Renewal, Growth, & Healing employee
Community event
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Primary insurance carrier: *Please indicate if you plan to self-pay* *
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What is your Member ID number for your primary insurance carrier? *Typically on the front of the insurance card*
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If applicable, what is your Group ID number for your primary insurance carrier? *Typically on the front of your insurance card*
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What is the Provider Services phone number for your primary insurance? *Typically on the back of your insurance card*
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Do you have a secondary insurance carrier? *
Interested in:
Which therapist would you prefer to work with? *
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What service(s) are you interested in? *
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Briefly describe the reason you are seeking therapy *
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To ensure that we can best serve you and determine if our physical space is suitable for you, please let us know of any physical and/or mental limitations needing accommodations.
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What days and times are you usually available for sessions? *Sessions usually last 45-55 minutes* *
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In order to accurately verify your insurance, it is important that we have a copy of your DMV-issued identification card and the front and back of the insurance card(s) that will be used for submitting claims. If the client is a minor, please upload the minor's student ID along with the parents/legal guardians' DMV-issued identification card.
The identification card(s) and insurance card(s) can be sent to info@renewalgrowthhealing.com. Please include the name and DOB of the person seeking services in the email subject.
In the space below, please provide any additional information you would like us to know.
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