New Client Services Request

Client's Name*

Date of Birth for Identified Client*

Phone*

Is it okay to text this number?*

Yes
No

Email*

Is the identified client a child?*

Yes
No
No but they do have a legal guardian

Is the child currently in DHS Custody?*

Yes
No

Name of DHS Case Worker*

Phone Number of DHS Case Worker*

County of current DHS case*

Parent or Guardian Name*

First and Last Name

Reason for Seeking Services*

You may be as broad or specific as you choose

Check all locations you would consider going to*

City/Town of Residence*

Would you like virtual appointments*

Yes
No
No Preference
Unsure - Would like more information

Would it be okay to have a counseling intern shadow your therapist during sessions?*

Yes
No
Yes but I would like more information about the intern before they join
I would like more information

You always have the option to change your mind about allowing interns to join. You also have the right to ask for specific requirements of the interns if you do allow them to join (i.e. you only want a male or female intern, LGBTQ friendly, etc.)

Would you be interested in seeing a Counselor in Training Graduate Student in order to be seen more quickly?

Yes
No
No Preference
Unsure - Would like more information

Do you have a preference on a male or a female counselor?

No Preference
Male
Female

Does the identified client have SoonerCare or Medicaid?*

Yes, they ONLY have Medicaid
No, they do not have Medicaid at all
Yes but they ALSO have ANOTHER type of insurance

Select ALL insurance coverage that applies to this client - If you are completing this form on a computer hold ctrl or command to select more than one insurance*

Front and Back of All Health Insurance Cards Except Medicaid - Failure to include pictures of ALL insurance cards may delay services.*

Drop files here or

Accepted file types: jpg, png, jpeg, pdf, Max. file size: 25 MB.

If cards are not provided and you incur charges that we are unable to submit to your insurance, you will be responsible for all charges not covered. If you are completing this form on your phone you can take a picture with your camera.

SoonerCare/Medicaid ID or Social Security Number*

If you do not know the SooneCare/Medicaid ID Number you must enter the client's social security number so we can look up the ID information.

Is anyone else in your household seeking or receiving services from Improving Lives Counseling Services*

Yes
No

Please list names of all other household members seeking/receiving services so we can coordinate services*

Click on the + button to add additional lines

Comments

This field is for validation purposes and should be left unchanged.

MEDICAID
Aetna
Aetna Coventry
Alliance Coal
Allied National
BlueCross Blue Shield
ChampVA
Cigna EAP Services
Cigna Health and Life Insurance Co.
Edison Health Solutions
GPA
Group Benefit Services (GBS)
Health Smart
Healthcare Highways
HealthCare Solutions Group
HealthChoice
HealthScope
HealthSmart
HealthSmart Benefit Solutions
Humana Military
HumanaChoice PPO
Medica
Medicare
Meritain Health
OPTUM VA
The Kempton Group
Tricare East
UMR - Wausau/UHIS
United Health Care/United Behavioral Health
WebTPA

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