EmailMe Form - Verification of Eligibility/Benefits

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
### - ### - ####
Please ensure your voicemail system is accepting messages.
Email
Prefered Contact Method
Telephone
Email
Name of Primary Insured
First Middle Last
Date of Birth of Primary Insured
Insurance Company
Blue Cross Blue Shield AL
Aetna
Cigna
NAMCI/Alternative Resources
United Healthcare/United Behavioral Health
Other:
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
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