Bridging Lyfe Health Consultation Form Name First Name Last Name Email * Phone * (###) ### #### Preferred Name Pronouns Date of Birth * Address * Zip Code * What are you looking forward to working on in therapy? What goals do you hope to acheive? * What is scheduling preference? (Mon.-Fri.) * Mornings Afternoons Evenings What is your preference? Virtual In-person What is your preference: individual, couples counseling or family counseling? * Individual Couples Counseling Family Counseling Primary Insurance Carrier's name (BCBS PPO/Aetna/Cigna etc.) * Policy Holder's Name Relationship to Client Self Parent Guardian Spouse Significant Other Date of Birth (if not self) Policy Holder Phone Number * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Group Number Policy Member Identification Number Will you be utilizing HRA, HSA, FSA, EAP or similar plans? If so, provide more information. Thank you!
