Express Referral Form – Edges Wellness Center

Home
About Us
Providers
Services & Fees
Group Sessions
FAQ
Employment

Home
About Us
Providers
Services & Fees
Group Sessions
FAQ
Employment

We appreciate your interest in Edges Wellness Center. Please fill out and submit the short form below and our Client Coordinator will be in touch shortly to discuss next steps and care options.

Full Name *

Pronouns

Email Address *

Phone Number *

Your State:

Preferred Contact Method (please select one) *

Ready to Get Started?

Home
About Us
Providers
Services & Fees
Group Sessions
FAQ
Employment

Home
About Us
Providers
Services & Fees
Group Sessions
FAQ
Employment

Your Privacy Matters
Terms and Conditions
Cookie Preferences

We appreciate your interest in Edges Wellness Center. Please fill out and submit the short form below and our Client Coordinator will be in touch shortly to discuss next steps and care options.

Full Legal Name *

Preferred Name (if different)

Pronouns

Date of Birth *

Parent or Legal Guardian Full Name (if applicable)

Email Address *

Phone Number *

Your State:

Preferred Contact Method (please select one) *

What type of therapy are you seeking? *

Do you have any specific preferences in terms of providers?

This could include if you would like to request any of our practitioners specifically, the availability your provider would need to match with your schedule needs, or if you have a type of therapy you prefer your therapist use.

What do you hope to address in therapy?

To the amount that is comfortable, please briefly describe below.

What days and times would work best for your schedule? *

What meeting setting do you prefer? *

In-Person

Virtual

How do you plan to pay for your services? For questions about rates and accepted insurances, visit our services and fees page.

Insurance

Private Pay

Insurance Information

Why are we asking for your insurance information up front?

We ask for your insurance details up front because it helps us match you with the provider who best fits your needs and coverage. Some of our clinicians are in-network with certain insurance plans, while others are not. Knowing this information from the start helps you avoid unexpected costs and makes sure we set you up with the right care from day one.

What is your current active insurance?

Feel free to select multiple options if you have multiple active insurances. We will ask for copies of your insurance cards in the future in order to verify eligibility.

Aetna

Blue Cross Blue Shield

Cigna

HealthPartners

Hennepin Health

Medica

Medicare

Minnesota Medical Assistance/ Medicaid

Preferred One

Ucare

United HealthCare

Tricare

Other

What is your primary insurance member number? *

What is your primary insurance group number? *

Consent to Treat and Bill for Services

By entering my name below, I give permission for the evaluation and/or treatment of myself (or my minor child whose name appears as the Client on this document). If the services require precertification to activate my benefits, I authorize the release to my insurance or managed care company any necessary information for the precertification. I authorize the release of any information necessary to receive reimbursement or to collect service fees.

*We will NOT bill your insurance until after you have completed a session with your provider *

How did you hear about Edges Wellness? *

Family/Friends

Another Therapist or Clinic

Community Event

Google/ Search Engine

Social Media

Other

Can you share more specifics about your selection (e.g., name of person, organization, or platform)?”

Is there anything else you would like for us to know?