Self Referral

Please fill out the referral form below. This form is fully HIPAA compliant and the information gathered will allow us to verify insurance benefits and will expedite the intake process. As soon as we have verified benefits we will call you back in order to schedule an appointment with one of our therapists. Please allow 24-48 hours for us to get back to you. Thank you.

The boxes marked (*) are required fields.

PERSONAL INFORMATION:

First Name:

Last Name:

Date of Referral

Date of Birth

Phone Number

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

TYPE OF INSURANCE:

(If "Self-Pay" type in N/A on required fields)

Member ID

Effective Date

Policy Holder Name

If Medicaid, PCP and Clinic

Do you have more than one insurance plans?

Yes

(If "Yes", please fill out fields below)

Secondary Insurance

Member ID

Effective Date

Policy Holder Name

If Medicaid, PCP and Clinic

Reason for Seeking Services

IMPORTANT: Please include a copy of your Insurance Card and ID (front and back)

Front of Insurance Card

Upload File

Back of Insurance Card

Upload File

Front of State Issued ID

Upload File

Back of State Issued ID

Upload File

By checking this box, I declare I have filled out this form to the best of my capacity and that the information provided is factual. I understand that the information I provided will be used solely for the purposes of the intake process for New Leaf Counseling of the River Valley, Inc.

Thanks for submitting! We will attempt to contact you within the next 24-48 hours in order to schedule your appointment.

Contact Us!

If you have questions about self-pay rates, services, etc. feel free to ask here. Please leave your name, contact email address, and a good phone number that we can call back. We will try to get in touch with you within 24-48 hours. If you do not get an e-mail back from us within that time frame, please check your junk mail, as many have reported this to be an issue. Thank you.