Verification of Eligibility/Benefits
If you are interested in using Insurance Benefits or Employee Assistant Benefits to pay for counseling services, please complete the following information. You may upload a copy of your insurance card to attach to this form.

By completing and submitting this information you are giving permission for the clinical and/or administrative staff of Kelly Counseling & Associates to view your benefits. Verification of benefits is not guarantee of payment. All information remains confidential.

Minor clients

While parents/guardians have a legal right to know what treatment modalities are being utilized and what charges are incurred during the course of counseling with their child, it is not supportive of the therapeutic relationship for counselors to share information the minor may disclose in confidence. Counselors will notify parents/guardians if there are any safety concerns, including any danger of the client harming him/herself or others. There may be times when parents/guardians want to share information regarding their child. Counselors may receive relevant information, however children ages 14 and older must give permission for the counselor to share return information and or have contact with either or both parents/guardians. By signing this form, you are acknowledging the agreement of our policy of counseling minors.
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    Please ensure your voicemail system is accepting messages.
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    Please ensure your voicemail system is accepting messages.
  • Requested Counselor
    If your requested counselor is unable to accept new clients at the time of intake form, you may be offered the option to see another counselor in the practice.