Client Portal - Bethany Robson, LCSW CPCC

Please provide as much information as possible, including address, phone, and insurance information, as well as your presenting problem/s and goal/s for therapy.

Personal Information:

First Name:*

Middle Name:

Last Name:*

Date of Birth:*

Gender of Legal Record:*

Male Female

Contact Information

E-mail:*

Phone:*

Address

Address type:		Street Address:

City:		State:

Zip code:

Legal Custodian

I am the client/patient seeking services.

I am a legal guardian, seeking services for someone under my care.

First Name:*

Last Name:*

Relationship:

Custodian Contact Information

E-mail:*

Phone:*

Custodian Address

Same address as client

Address type:		Street Address:

City:		State:

Zip code:

Provider:

Please explain the reason you are seeking help at this time.

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

If you are in crisis or having an emergency, please act quickly to call 911, or go to urgent care or the emergency department of your nearest hospital.

Private pay/Cash pay

Insurance:

Insurance Company Name:*

Member #:

Insurance Secondary:

Secondary Insurance Company Name:

Member #:

EAP Information:

Employee Assistance Program Name:

EAP Authorization Code:

Phone Number:

Submit

Cancel

Please provide as much information as possible, including address, phone, and insurance information, as well as your presenting problem/s and goal/s for therapy.

Personal Information

Contact Information

Phone

Address

Provider:

Please explain the reason you are seeking help at this time:

Insurance

Insurance Secondary