Treatment Inquiry

Date

Caregiver Name(Required)

First Last

Home Phone Number(Required)

Cell Phone Number

Email Address

Providing an email address, if available, helps us connect you to needed services as efficiently as possible.

Caregiver Address(Required)

Street Address Address Line 2 City State ZIP Code

Relationship to Client(Required)

Client Name(Required)

First Last

Client Date of Birth(Required)

Client Gender(Required)

Client's Preferred Pronoun

Client Address(Required)

Street Address Address Line 2 City State ZIP Code

Client's Current Services & Providers(Required)

Current Tanager Place client?(Required)

Yes

Interested Services

Therapy (individual/group/family)

Medication Management

Reason for Inquiry:(Required)

Please include information about current symptoms, behaviors, functioning and trauma

Insurance & Documentation

Please attach copy of insurance card and ABA documentation, if applicable, in upload section below. Insurance verification required before appointment. Tanager Place is unable to accept Medicare insurance at this time. Private pay rates are available for insurances out of network. While insurance information is not required as part of this form, providing it now will expedite the path to treatment.

Medicaid Type

Medicaid ID:

Amerigroup Number:

Name on Medicaid/MCO Card:

First Last

Private Insurance: Subscriber's Name

First Last

Blue Cross Blue Shield Provider

Blue Cross Blue Shield Provider ID

Private Insurance: Subscriber's Date of Birth

Private Insurance: Employer Name

Private Insurance: Policy Number/Member ID

Private Insurance: Group Number/Plan Name

Insurance & Documentation Upload

Drop files here or

Accepted file types: jpg, pdf, png, gif, Max. file size: 50 MB.

How did you hear about us?(Required)

Treatment Inquiry

Insurance & Documentation

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