Contact Behavioral Health Therapy Services

I am:* Looking for services for myself Referring a loved one A provider referring a patient

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Please provide your information:

Your First Name:*

Your Last Name:*

Your phone number:*

Your email address:*

Your relationship to client:

Child

Sibling

Spouse/Partner

Friend

Other

Please provide us with your loved one's information:

Client's first name:*

Client's last name:*

Client's Date of Birth:*

MM slash DD slash YYYY

Client's Street Address*

City*

State*

Zip Code*

Client's phone number:*

Client's email*

Consent to Outreach Client*

Yes

The client is aware of this referral and is expecting Forge Health to contact them directly via phone, voicemail, SMS/text, and email as appropriate.

Please provide us with your loved one's insurance:

Client's Insurance Type*

Forge Health partners with most major insurance companies. *Medicaid and Medicare are accepted at select locations.

Insurance Provider*

If your insurance provider is not on this list, please select "Insurance Not Listed"

Client's Member ID*

Your member ID can be found on your insurance card. If your member ID is alphanumeric, please include both the letters and numbers you see on your card.

List Insurance Provider Here:*

Please provide the name of your loved one's insurance company and upload images of both the front and back of your insurance cards.

Insurance Card Upload (front)

Max. file size: 256 MB.

Insurance Card Upload (back)

Max. file size: 256 MB.

How can we best support your loved one?

Is the client interested in In-Person or Telehealth services?*

In Person

Telehealth

Is the client interested in services for Mental Health or Substance Use?*

Mental Health

Substance Abuse / Addiction / Alcohol

Other

What type of program are you interested in today?*

Intensive Outpatient Therapy (IOP)

Individual Therapy

Couples Therapy

Family Therapy

Psychiatric Evaluation

Medication Management

Medication Assisted Treatment (MAT)

Tell us a little more about how we can best support your loved one:*

Preferred Location for Services:

Preferred Location for Services:*

Preferred Location for Services:

Preferred Location for Services:*

Preferred Location for Services:

Preferred Location for Services:*

How did you hear about Forge Health?

How did you hear about us?*

Internet Search

Social Media

Healthcare Professional / Organization

Family Member / Friend

Employer / EAP

Insurance Directory / Card

Other

Name of Healthcare Provider or Organization*

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formId

Please provide your information:

Your first name:*

Your last name:*

Date of Birth*

MM slash DD slash YYYY

Your phone number:*

Your email address:*

Consent to SMS*

Yes

By entering my mobile number and checking this box I agree to receive Opt in to receive important messages from Forge Health regarding appointment reminders, events, and general information about our services. Msg frq varies Text HELP to 36732 for help, Text STOP to 36732 to end. Msg&Data Rates May Apply. By opting in, I authorize Forge Health to deliver SMS messages using an automatic telephone dialing system and I understand that I am not required to opt in as a condition of purchasing any property, goods, or services. By leaving this box unchecked you will not be opted in for SMS messages at this time. Click to read Terms and Conditions, and Privacy Policy

Consent to Email*

Yes

By entering my email and checking this box I agree to receive email communications from Forge Health regarding appointment reminders, events, and general information about our services. I understand that I can unsubscribe from these emails at any time by following the unsubscribe link provided in each email.

Address*

City*

State*

Zip Code*

Please provide your insurance:

Insurance Type*

Forge Health partners with most major insurance companies. *Medicaid and Medicare are accepted at select locations.

Insurance Provider*

If your insurance provider is not on this list, please select "Insurance Not Listed"

Member ID*

Your member ID can be found on your insurance card. If your member ID is alphanumeric, please include both the letters and numbers you see on your card.

List Insurance Provider Here:

Please provide the name of your insurance company and upload images of both the front and back of your insurance cards.

Insurance Card Upload (front)

Max. file size: 256 MB.

Insurance Card Upload (back)

Max. file size: 256 MB.

How can we best support you?

Are you looking for In-Person or Telehealth Services?*

In Person

Telehealth

Are you looking for services for Mental Health or Substance Use?*

Mental Health

Substance Abuse / Addiction / Alcohol

Other

What type of program are you interested in today?*

Intensive Outpatient Therapy (IOP)

Individual Therapy

Couples Therapy

Family Therapy

Psychiatric Evaluation

Medication Management

Medication Assisted Treatment (MAT)

Tell us a little more about how we can best support you:

Location Preference:

Preferred Location for Services:*

Location Preference:

Preferred Location for Services:*

Location Preference:

Preferred Location for Services:*

How did you hear about Forge Health?

How did you hear about us?*

Internet Search

Social Media

Healthcare Professional / Organization

Family Member / Friend

Employer / EAP

Insurance Directory / Card

Other

Name of Healthcare Provider / Employer / Organization*

CAPTCHA

Hidden

formId

Please provide your information:

Your First Name:*

Your Last Name:*

Your phone number:*

Your email address:*

Title:*

Organization, please specify branch if relevant:*

Please provide us with the patient's information:

Patient's first name:*

Patient's last name*

Patient's date of birth:*

MM slash DD slash YYYY

Patient's Address*

City*

State*

Zip Code*

Patient's Email*

Patient's phone number:*

Patient insurance information:

Patient's Insurance Type*

Forge Health partners with most major insurance companies. *Medicaid and Medicare are accepted at select locations.

Patient's Insurance Provider:*

If your insurance provider is not on this list, please select "Insurance Not Listed"

Patient's member ID:*

Your member ID can be found on your insurance card. If your member ID is alphanumeric, please include both the letters and numbers you see on your card.

List Insurance Provider Here:*

Please provide the name of your insurance company and upload images of both the front and back of your insurance cards.

Insurance Card Upload (Front of Card):

Max. file size: 256 MB.

Insurance Card Upload (Back of Card):

Max. file size: 256 MB.

How can we best support your patient?

Is the patient interested in in-person or telehealth services?*

In Person

Telehealth

What is the patient's primary need?*

Mental Health

Substance Abuse / Addiction / Alcohol

Other

Which level of care are your recommending for the patient? (select all that apply)*

Intensive Outpatient Therapy (IOP)

Individual Therapy

Couples Therapy

Family Therapy

Psychiatric Evaluation

Medication Management

Medication Assisted Treatment (MAT)

Tell us a little more about the patient and their current needs:*

Additional Paperwork Upload

Drop files here or

Max. file size: 256 MB, Max. files: 4.

Location Preference:

Patient's Preferred Location for Services:*

Location Preference:

Patient's Preferred Location for Services:*

Location Preference:

Patient's Preferred Location for Services:*

Consent to Outreach Client*

Yes

I give or have obtained any necessary consent/authorization prior to disclosing the health information above. The patient is aware of this referral and is expecting Forge Health to contact them directly via phone, voicemail, SMS/text, and email as appropriate.*

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