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CURRENT CLIENT:  FORMS

 

 

 

 

 

 

 

 

*All Forms are Mobile Friendly / Electronic Forms that are HIPPA compliant, and ENCRYPTED which means your information is safe and secure. 

This form is for Current Clients to authorization to input your Credit Card and / or Health Savings Account Card / Flexible Spending Account Card  information into our secure system and charge it when a balance on your account exists.

This form is for Current Clients to request to Add or Update any of the following:  Contact Information, Legal Name; Mailing Address; Phone Number; and or E-Mail Address on file. 

CURRENT CLIENTS:  NEW INSURANCE / APPT. REQUEST FORM  LINK

 

How do I Update my Insurance & Receive a NEW Benefits Quote? 

 

For a NEW Benefits Quote due to a NEW Insurance Policy; Additional Insurance; SAME Insurance Company - NEW Plan; Policy Renewal (i.e. New Year) as a Current or Returning Client simply fill out the Appointment Request Form via Link:  https://intakeq.com/new/AverCw   

This form is for Current Clients to update medications on file when medications change.  There are drop down boxes for each row of Medication(s) as follows:  Prescribed For; Frequency Prescribed; Start Date, and for Medication Effectiveness; please fill out accordingly. 

This form is an assessment tool, simply check all symptoms/presenting problems that apply from list and note how long the symptoms have been present for.  This is an important assessment tool for diagnosing and determining client meeting medical necessity for treatment or not.  Moreover, your insurance company requires that you meet medical necessity in order for the insurance company to continue to cover your sessions hence these assessments are necessary.  If you no longer meet medical necessity you may still be seen as a private pay client.       

BECK DEPRESSION INVENTORY-II 

This is an assessment tool to assess the magnitude of client's level of Depression; form only takes 5-7 minutes to fill out.

*This assessment will be e-mailed to you every 3-months to prove medical necessity. 

BECK ANXIETY INVENTORY

This is an assessment tool to assess the magnitude of client's level of Anxiety; form only takes 5-7 minutes to fill out.

*This assessment will be e-mailed to you every 3-months to prove medical necessity.