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Ready to Begin the Counseling Journey?

Please complete the following form and you will be contacted within three business days regarding your benefits and/or counselor availability. 

We accept new clients based upon counselor availability at the time we receive your information.

 

If we are unable to schedule you to begin services, we will provide you will referral information for other counselors in the area. 

If your preferred counselor does not have openings, we will do our best to find another counselor best suited for your needs.

 

If you do not have internet access, please contact us at 256-712-5665.

Please have the information below available.

 

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 Phoenix Counseling and Resources, LLC 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 (First, Middle, Last)*

Name of Legal Guardian, if client is a minor*

Email Address*

Phone*

Preferred Method of Contact*

Address*

Date of Birth of Potential Client*

Method of Payment*

Name of Primary Insured (First, Middle, Last)

Date of Birth of Primary Insured

Insurance Company

Member ID/Contract ID

Group Number

Type of Counseling Services*

Reason for Seeking Support*

Requested Counselor*

Office Hours

Mon-Thurs: 9:00am - 5:00pm
Sat: Closed
Sun: Closed

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