EmailMeForm
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
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Phone number
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Please ensure your voicemail system is accepting messages.
Phone of parent/guardian if client is 13 years or younger.
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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
Please select
Individual counseling for child
Individual counseling for adult
Couples/family counseling
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
Please select
Alicia Kelly, LPC-S
First available
Michelle Bolton, LPC-S
Brian Knight, LPC
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