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Limitless Possibilities
Services
Referrals
About
Meet the Team
Blog
Speaking Engagements
Limitless Endeavors
AIM
Mentor
Career Opportunities
Shop
Request Youth Mentorship
Connect with a Counselor
Treatment Modalities
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Client Name
Legal Guardian’s Name (if applicable)
Phone Number
Client's Date of Birth
Email
Client’s Address:
Referral Source Name
Referral Source Telephone Number
Emergency Contact Full Name
Emergency Contact Phone Number
Emergency Contact Email
Social Security Number (to verify insurance coverage)
Primary Care Insurance Name
Primary Care Insurance Number
Primary Care Insurance Telephone Number
Upload a Photo of Insurance Card
Upload a Photo of the back of your Insurance Card
Secondary Insurance Name.
Secondary Insurance Ins Number
Private Pay
Yes
No
Member ID Number
Are there other service providers involved (CSA, Psychiatrist, CBI)?
Yes
No
If “Yes” is checked above, please provide the contact information:
Services Needed/Requested
Individual Therapy
Family Therapy
Intensive Mentoring/CBI
Marital Therapy
Other
Does Client attend School?
Yes
No
If “Yes” is checked above, please provide the name of the school client attend
Presenting Problem or Area of Concern
Submit