Health Insurance Contact Form

Note: I am not providing Marriage/Couples Counseling at this time. I only provide Individual Counseling to Adults 18 yrs and up.
***If you have not received confirmation that this form was received by email within 3-5 business days please resubmit the form as it likely was not received***

Client First name

Client Last name

Client Gender

What state are you located in?

Virginia

North Carolina

Other

Counselor is only licensed to provide Telehealth Services in Virginia and North Carolina. You must be in one of these states during the time of session in order to receive services.

Do you have an active Medicare Policy?

Yes

Do you have an active Medicaid Policy?

Yes

Counselor does not accept NC Medicaid

Who is your Health Insurance Provider? (If no Health Insurance type "Self-Pay")

Are there any certain days or times you would need services due to other obligations?

Current appointment times are Monday, Wednesday, and Thursday 10:00 am-5:15 pm. I am closed Tuesday, Friday, Saturday, and Sunday.

What issues/problems were you wanting to address in counseling services?

Example: Anxiety, Depression, Grief/Loss, etc.

Do you have a secondary insurance or supplemental policy? If so, list the Insurance Provider here.

Message- If you want to use your EAP (Employee Assistance Program) Benefits please include the Authorization number and number of sessions here.

Please be aware that all counseling sessions are by Telehealth Only. You will need access to the Internet, your own phone for counselor to get in touch with you in case of technical difficulties during the session, and your own email address where you can receive appointment reminders and document requests. Please be aware that not all issues/problems are appropriate for Telehealth counseling sessions. If at any time counselor feels you would benefit more from In-Person Counseling sessions you will be given a list of other providers in your area.

Living Water Counseling Ministry

Health Insurance Contact Form