EmailMe Form - Verification of Eligibility/Benefits

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.

Name of Potential Client
First Middle Last
Name of Parent/Guardian (if potential client is a minor)
First Middle Last
Date of Birth of Potential Client
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone number
### - ### - ####
Please ensure your voicemail system is accepting messages.
Phone of parent/guardian if client is 13 years or younger.
### - ### - ####
Please ensure your voicemail system is accepting messages.
Email of potential client, 14 years or older.
Email of parent/guardian if client is 13 years or younger.
Prefered Contact Method
Telephone
Email Due to back to back sessions, secure email is the most efficient method of communication).
Due to back to back sessions, secure email is the most efficient method of communication).
Name of Primary Insured
First Middle Last
Date of Birth of Primary Insured
I
Blue Cross Blue Shield AL
Aetna
Cigna
NAMCI/Alternative Resources
United Healthcare/United Behavioral Health
Private Payment
Member ID/Subscriber ID/Contract Number
(include all letters and numbers on insurance card)
Group Number/Plan
File Upload
Employee Assistance Plan
American Behavioral
Aetna Resources for Life
Behavioral Health Systems
Carebridge
Compysch
Other
Private payment
Authorization Number/Code
Number of EAP sessions approved
Name of Employer (this remains confidential)
Type of Counseling Services of Interest
Reason/s For Seeking Support
(this remains confidential)
Depression
Anger Issues
Anxiety
Trauma
Relationship Conflict
Addictive Behaviors
Child/Teen Behavior Issues
LGBT Issues (affirming)
Other
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.
Multiple Choice
First option
Second option
Third option