Contact — Animal Companion Counseling

Contact us

admin@animalcompanioncounseling.com
(513) 401-5145

We currently accept Medicaid and most commercial insurances. Please allow two weeks for scheduling once your referral is submitted. As our access to information is limited, and insurance policies are subject to change without notice, we encourage all clients to verify their plan benefits and coverage directly with their insurance carrier prior to beginning services.

Legal Client Name

First Name

Last Name

Preferred Name

Pronouns

Who referred you to us?

Guardian Name (if applicable)

First Name

Last Name

Client Date of Birth

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Social Security #

Insurance Type

Insurance #

Primary Insured's Name

If other than self, required to verify insurance as active

Primary Insured's Address

If other than self, required to verify insurance as active

Primary Insured's Date of Birth

If other than self, required to verify insurance as active

YYYY

Primary Insured's Phone #

(###)

###

####

Group ID

MMIS # (Required for all Medicaid Insurances)

Secondary Insurance

Yes

Secondary Insurance (if applicable)

Insurance Type, Primary Insured's Name and Insurance #

Service of interest

Diagnostic Assessment, Individual Counseling, Group Counseling and/or Clinical Supervision

Reason for Referral

What would you like to change or improve in your life?

Availability

What is your best availability?

Message