CLS Counseling & Consulting, PLLC

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

What sex is on your insurance policy?

For insurance verification

State

Select the state you live in

Pronouns

She/Her Him/He They/Them She/Them He/Them Other

Billing & Payment

How do you plan to pay?

If you have insurance and plan to use it, please upload a photo of the front and back of your card. This helps us confirm we're in network and check your benefits before we meet.

Got it, I'll upload it I'd rather chat about it first

Insurance card upload

Upload a photo of your insurance card

If you have insurance and plan to use it, Are you the primary subscriber on this insurance plan?

Yes, I'm the primary subscriber No, someone else is the primary subscriber

If no, please provide the following for the primary subscriber: Full Name, Date of Birth, Address, Relationship to You:

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.