Access For Change, LLC Request For Services

Access For Change,LLC

Service request Form
Access For Change, LLC

is

Accepting Referrals
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Method of Contact
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status
Why you are seeking treatment?
Were you referred to a specific therapist? If yes please identify from list.
Primary Care Physician Name
Primary Care Telephone Number

Area CodePhone Number
Emergency Contact Information
Name of Emergency Contact

First NameLast Name
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship To Emergency Contact
Are You Using Health Insurance ?
If yes, what is your Primary Health Insurance?
Do you have a secondary Health Insurance Plan? If yes, please list.
If you are using insurance,

call our billing office.

at 800-946-1101.

Once we receive your Insurance Information, we wil contact you.
Medical History
Please check all the apply

Other
Caffeine use?
Do you use tobacco?
Do you use alcohol?
Are you currently taking prescription medication?
If taking medication prescriber Name & Number

First NameLast Name
Medication Provider
Format: (000) 000-0000.
Family history

Other
What type of Service are you requesting
Mental Health History
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

Other
Are you requesting ?
Please verify that you are human
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Access For Change,LLC

Access For Change, LLC

is

Accepting Referrals

Emergency Contact Information

Medical History

Mental Health History