Creative Psychological Health Services, LLC

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

If you are answering this form on behalf of someone else (child, spouse, etc) PLEASE CONFIRM THAT THE ANSWERS TO THE DEMOGRAPHIC QUESTIONS ABOVE ARE ABOUT THE POTENTIAL CLIENT, AND NOT YOURSELF :)

If you are answering this form on behalf of someone else, please list your name here, as well as your relationship to the client. If you are completing this form for yourself, please answer "NA" below.

Client's pronouns

If you would like to share information about the client's race/background/ethnicity, feel free to do so here.

Languages spoken in the home

Child's current school and current grade level

Answer "NA" for clients who are not minors

Does the child receive any special education services/have an IEP or 504 in place? If so, please explain in brief detail below.

If this does not apply, please answer "NA"

Administrative

How did you hear about our practice?

If you are filling out this form for a minor, please share the marital status of their caregivers below.

If you are not filling this form out for a minor, please type N/A in the answer box.

If you are filling out this form for a minor, and a custodial agreement is in place, please list the name and contact information for additional custodial caregivers here. If you are not filling this form out on behalf of a minor, or this question does not apply, please type "NA" in the answer box.

In cases of divorced and/or separated parents, CPHS providers will request the most recent custody and/or visitation orders (including separation agreements) prior to starting services, in order to clarify the current status of physical and legal custody. All custodial caregivers will be required to consent for the child's care at our practice.

Billing & Payment

Licensed providers at Creative Psychological Health Services are in network with most insurances under the CareFirst/BCBS and Cigna/Evernorth umbrellas, provided the plans are not Medicaid/Community Health based. Superbills can be provided to you by our practice for submission for out of network reimbursement, if that is a part of your coverage. We also have masters level interns who are unable to bill insurance, and therefore see clients at a significantly reduced out of pocket fee.

Please choose one or more of the following:

Plan under CareFirst/BCBS umbrella, non Medicaid/Community Health based Plan under Cigna/Evernorth umbrella, non Medicaid/Community Health based Hopkins EHP - Utilizing CareFirst/BCBS provider network Hopkins EHP - Utilizing Cigna/Evernorth network Reduced out of pocket intern rate Covered by a NON CareFirst/BCBS or Cigna/Evernorth plan, but would like superbills to submit for out of network reimbursement

Insurance card upload

Upload a photo of your insurance card

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.