Initial Appointment / Information Request

If you are a new client and would like to request an initial appointment or a verification of insurance benefits please complete this form and someone from our office will contact you as soon as possible. Current clients should contact their therapist directly to schedule appointments.

*Now accepting new clients for Intensive outpatient and outpatient services

Patient Information

Patient Name

First Name

Last Name

Patient Age

(We treat teens & young adults 14-30)

Patient Date of Birth

Patient Email

Patient Address

Patient Cell Phone

(###)

###

####

Insurance information

Insurance Plan Name

Insurance Policy Number

Primary Policy Holder Name

First Name

Last Name

Insured's Relationship to Patient

Primary Policy Holder Date of Birth

YYYY

Primary Insured's Email

Seconday Insurance Information

Please provide above information for secondary plan (if applicable)

Patient History

Please provide all requested information. This will help determine your insurance coverage

Reason for Treatment

(Brief description about why you're seeking therapy. Including level of care -Intensive Outpatient or Outpatient -if known)

Past or current substance use?

(Including ANY alcohol or marijuana use)

Submitter's Information

Relationship to patient

Name

First Name

Last Name

Phone

(if different than information provided above)

(###)

###

####

(If different than information provided above)

Additional Information

Additional Parent/Guardian Contact information

(Please include mother and father's name, email and phone number)

Additional Comments?

Initial Appointment / Information Request

Serenity Behavioral Health

145 N. Eagle Rd. Havertown, PA 19083

Initial Appointment / Information Request

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