Couples & Family Service Form

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Couples & Family Service Form

Couples & Family Service FormAdmin2022-05-26T15:15:59+00:00

Name of Person Submitting Form

Preferred Pronouns

Preferred Name

Phone Number *

Email *

Address *

Street Address Line 2 *

City *

State / Province *

ZIP / Postal Code *

Country

Date of Birth

Insurance Company *

Group Number *

ID Number *

Who is the policy holder for your insurance plan?SelfSpousePartent

Name of Policy Holder

Policy Holder's DOB *

Policy Holder's AddressStreet Address

Street Address Line 2

City

State/Province

ZIP / Postal Code

Country

Name and ages of partner and/or family members who will participate in therapy (for children, please list ages)

Are you seeking services in response to a divorce, separation, and/or co-parenting challenges? *YesNo

Is there a court or parenting consultant order or recommendation for the services you are seeking? *YesNo

What services, to your understanding, are you seeking from KESMA Flame Lily Family Services? Check all that apply *Individual Therapy for youIndividual Therapy for your child(ren)Co-Parenting Therapy/CoachingReunification TherapyFamily TherapyOther

If you listed "other" to the question above, please specify any other services you are seeking

Is a parenting consultant, guardian ad litem, and/or custody evaluator currently involved with your family? *YesNo

Please provide any additional information you believe would help us understand your situation and reason(s) for seeking services

Preferred Office Location

* Before KESMA Flame Lily Family Services can begin providing services to any client, we MUST have the insurance carrier, member ID # and group number as it appears on their member ID card. For example, if a client has PMAP coverage, we will need the specific PMAP plan information (insurance provider name, member ID and group #), before we can schedule an intake. If a client has straight Medical Assistance, we will just need their MA/PMI #

Please note that not all services offered by KESMA Flame Lily Family Services are billable to insurance, even if the therapist is listed as in-network by your insurance provider. We will do our best to anticipate and explain potential out-of-pocket expenses prior to initiating services

I acknowledge that not all services may be covered by insurance.

Are you a current or past KESMA Flame Lily Client?

As soon as we receive a referral, KESMA Flame Lily staff will begin processing and verifying insurance coverage. If a client has "inactive" insurance, we will not be able to schedule an intake until we have confirmed that insurance is active. If a client has a PMAP plan, and we do not have the plan name, member ID and group numbers, we will not be able to schedule an intake. We will work with you, the referral source, to work on ensuring that coverage is in place. Thank you for working with us. We appreciate the support and assistance in coordination.