Mental Healthcare counseling intake

Birchwood Healing Place

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- Chyenne
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Please note this form must be filled out in its entirety even if the answer is N/A, none, or no, Otherwise it will not allow you to submit the form. Once the form has been received someone from this office will reach out to you.

* Indicates required field

First name *

Last name *

Date of Birth *

Phone Number *

Email *

Method of payment *

Cash Credit Card Insurance

Insurance Type *

Aetna Aetna Medicaid Cigna Anthem Commerical Anthem Medicaid Humana Commercial Humana Caresource KY marketplace Humana Medicaid Passport Medicaid Optum Wellcare Medicaid UMR United Health United Health Medicaid Other None

Member ID *

Phone number of back of card *

Co-Pay Amount *

We encourage you to contact member services with your insurance company prior to your first appointment and inquire about deductible, co-payment and or coinsurance for CPT code 90837. In the meantime put N/A if you do not know this information. All KY medicaid plans are 0.00 copay at this time.

Primary insured name, if you are on someone else's policy *

Primary Insured date of birth , if you are on someone else's policy *

Primary Insured address, if you are on someone else's plan *

Can you described in a few sentances or less why you are seeking care at this time? *

Are you involved in an open DCBS/ CPS case? *

CPS stands for Child Protective Services.

Are you involved an ongoing custodial dispute at this time? *

Are you involved in an open / pending SSI case? *

How did you hear about Birchwood Healing Place *

Submit

​Please note this form must be filled out in its entirety even if the answer is N/A, none, or no, Otherwise it will not allow you to submit the form. Once the form has been received someone from this office will reach out to you.

Please note this form must be filled out in its entirety even if the answer is N/A, none, or no, Otherwise it will not allow you to submit the form. Once the form has been received someone from this office will reach out to you.