Bridging Lyfe Consultation Form

Insurance: We accept Insurance & Employee Assistance Programs, BCBS IL, Cigna, United Healthcare, Aetna, and Medicaid ( Meridian & County Care)

Is your plan not on the list? No worries! Fill out the form with your insurance information and we’ll be in touch!

Name

First Name

Last Name

Phone

(###)

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Preferred Name

Pronouns

Date of Birth

Address

Zip Code

What are you looking forward to working on in therapy? What goals do you hope to acheive?

What is scheduling preference? (Mon.-Fri.)

What is your preference?

What is your preference: individual, couples counseling or family counseling?

Primary Insurance Carrier's name (BCBS PPO/Aetna/Cigna etc.)

Policy Holder's Name

Relationship to Client

Date of Birth (if not self)

Policy Holder Phone Number

(###)

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Group Number

Policy Member Identification Number

Will you be utilizing HRA, HSA, FSA, EAP or similar plans? If so, provide more information.