| Which Service are you interested in receiving at TLC? |
Psychological Testing
Bariatric Testing
Executive Coaching
Individual Therapy
Family Therapy
Couples Counseling |
| Is there a specific Clinician with whom you are interested in working? |
|
| Which location is your preference? |
200 W. Matthews Street, Matthews, NC 28105
5701 W. Slauson Avenue, Suite 100, Culver City, CA 90230 |
| We will do our best to accomodate your preferences ~ What day and time would be most convenient to receive services? |
|
| Name: |
|
| Address: |
|
| Telephone Number: |
|
| May we leave at message for you at this number? |
Yes
No |
| Client Date of Birth: |
|
| Marital Status |
Single
Married
Widowed
Divorced
Separated
Living as Married |
| Email Address: |
|
| If Client is a Minor, Name and Number of Legal Guardian: |
|
| If you are using insurance to pay for your services, Please check with your carrier to be sure that TLC clinician you are choosing is paneled. What Type of Insurance you will be using |
Aetna (only in NC)
Blue Cross / Blue Shield (NC)
CBHA (NC)
Cigna (CA & NC)
Humana (NC)
Magellan (NC)
Medcost (NC)
Medicaid (NC)
Medicare
Tricare (NC)
United Healthcare (NC) |
| What is the Member / Subscriber number on the front of your card? (please include letters and dashes) |
|
| What is the Group number on the front of your card? |
|
| On the back of your card, what is the number for Provider Services and / or mental health benefits? |
|
| Who is the Primary Insured (policy holder)? |
|
| What is the Policy Holders name |
|
| What is the Policy Holders Date of Birth |
|
| How were you referred to TLC? |
Physician
Therapist
School
Attorney
Insurance Company
Psychology Today
Website |
| Please be so kind as to tell us Who Specifically referred you, so that we can thank them! |
|