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Client Care Screening
Please complete the form below and we will reach out to you once we are able to match you with a provider who has availability. For any questions visit
www.foundationsfamilysupport.com
or call 1-855-995-6777. Should you be in crisis, please contact the Suicide Prevention Lifeline at 1-800-273-8255 or 988. In emergencies, dial 911.
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* Indicates required question
Who is completing this screening?
*
Adult Client
Current Client Requesting a Change in Provider
Parent of Child 13 years old or older
Parent of Child 12 years old or under
Referring Professional
Age of Client
*
Your answer
I am a returning client
*
Yes
No
Not sure
Where would you prefer to receive services?
*
Check all that apply. For telehealth services, requires high speed internet, smartphone, tablet, or webcam computer. Pride Schools are for currently enrolled Pride School Students.
Telehealth Virtual Video Appointments (Soonest Availability)
Bradenton FL
Required
What services may be helpful?
*
Individual Therapy
Couples or Family Therapy
Medication Management
Support Groups
Required
Primary Insurance:
*
Choose
Aetna
Ambetter Sunshine Health Medicaid
Asuris
First Choice
Kaiser
Magellan
Optum/United
Premera Blue Cross Blue Shield
Providence
Regence Blue Cross Blue Shield
TriCare
Other/Self-Pay
Secondary Insurance:
Choose
Aetna
Ambetter Sunshine Health Medicaid
Asuris
First Choice
Kaiser
Magellan
Optum/United
Premera Blue Cross Blue Shield
Providence
Regence Blue Cross Blue Shield
TriCare
Other/Self-Pay
Primary Insurance ID:
*
Your answer
Secondary Insurance Member ID:
Your answer
Please Confirm:
*
Phone number OK for Foundations to call
Email OK for Foundations to contact
Required
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