Adaptive Human Solutions & Consulting LLC

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First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Reason for care

What are you most focused on?

Processing and Recovery Skills Growth Reflective Insights Not sure

Administrative

Inquiry reason

Please identify your referral source

How you were referred to our services?

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Insurance card upload

Upload a photo of your insurance card

Secondary Insurance Information

Insurance Plan, Primary Holder (& their birthdate), Member ID

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Client Preferences

Preferred appointment times

Days and Times

Morning Afternoon Evening Weekend

Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.

Who would be receiving care?

Your info