Health Insurance Pre-Enrollment Form

Name

Email Address

Phone

Address

City

State

Zip Code

Policy Holder Date of Birth

Health Insurance Carrier Name

Policy Holder Name

Name of Client

Client Date of Birth (Person Receiving Counseling)

Policy Number of Client

Gender Preference of Counselor (Male/Female/No Preference) Gender Preference of Counselor (Male/Female/No Preference)MaleFemaleNo Preference

Preferred Days/Times of Appointment (M-F 8am to 4pm, M-F 5pm-9pm, Sat 8am-9pm) Preferred Days/Times of Appointment (M-F 8am to 4pm, M-F 5pm-9pm, Sat 8am-9pm) M-F 8am to 4pm M-F 5pm-9pm Sat 8am-9pm

What type of counseling are you seeking? What type of counseling are you seeking?Marriage counselingPre-marital counselingIndividual counselingFamily counselingChild counseling

Briefly describe your reason for counseling (this will help us place you with a counselor more quickly)

Other Notes