Client Assignment | Improving Lives Counseling Services

Client First Name*

First 5 Letters of Client Last Name*

Insurance ID number from NCF Form*

Reason for Adding*

Clinician Making the Request*

Assignment:*

Assessment and Treatment Plan ONLY
Therapy Sessions
CM and/or BHRS

Clinician Email Address*

Verification*

I verify that I have already checked TH to see if I have been added

I verify that I have expanded the letters for both first name and last name to see if I have already been added to this chart before submitting this form.

Client Assignment Request