New Client Form | CORE Empowerment

Thank you for choosing CORE Empowerment! All new clients must complete this form before scheduling an appointment.

First Name *

Last Name *

Phone *

Email *

Are you a new or returning client? *

New Client

Returning Client

Service *

Individual Counseling

Family Counseling

Couples Counseling

Group Counseling

Who is this service for? *

Self

Child

Couple

Family

Date of birth *

How will services be covered? *

Self Pay

CareFirst (BCBS)

Cigna

Tricare

Maryland Medicaid

United Healthcare

Aetna

Please note, it is your responsibility to contact your insurance to verify the coverage of your services. Failure of insurance coverage will result in your responsibility for payment.

If using insurance, what is your Member ID number? *

If using insurance, what is your Group ID number? *

If using insurance, what is the phone number for providers? (Located on the back of your insurance card). *

Are you the policy holder? *

Yes

No

Name of policy holder *

Relationship to policy holder *

Date of birth for the policy holder *

Please Upload Front of Insurance Card *

Front of Card

Please upload back of Insurance Card *

Back of Card

Please upload front of ID *

Front of ID

Phone number of policy holder. *

Address of the policy holder. *

City *

State *

Postal code *

How soon are you looking to schedule? *

ASAP

This week

Next week

Next month

Are you currently or in the last 3 months had suicidal or homicidal thoughts or attempts? *

Yes

No

Best time to reach you at the number provided? *

How did you hear about us? *

What has prompted you to seek services at this time? *

Any additional information? *