Medicaid Services Request Form

Welcome to Healing Spaces Psychological Services! We're here to ensure a smooth and supportive process for potential clients with Medicaid. Please note that we will not begin to accepting clients with Medicaid until February or March, so you may not hear from us until then. 

Please take a moment to fill out this form to help us better understand your needs. Rest assured, your information is confidential.

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Email *
What is your name? *
What is the date of birth for the client? *
MM
/
DD
/
YYYY
What is the best number to reach you?
If you are completing the form for someone else, what is their name?
Is the appointment for an adult or minor *
If it's for a minor, does someone else share custody of the child? *
If so, what is their name and contact information? Write N/A if that is the case. 

 *
Indicate what type of service you are seeking *
Briefly describe why you are seeking our services
 *
Select your specific Medicaid program
 *
Required
Please provide your Medicaid number for verification purposes
 *
Feel free to provide any additional details you think are important.
Thank you!
Thank you for taking the time to fill out this form. Your well-being is our priority, and this information helps us tailor our services to meet your unique needs. Someone will be in touch with you in 2-3 business days. If you have any questions, don't hesitate to reach out to us.
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