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Client Portal

New Client Inquiry Form

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



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

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



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