Submit a request – MySpectrum Counseling & Coaching

Your email address

Subject(optional)

What kind of therapy are you seeking?

Patient Legal First Name

Patient Legal Last Name

Patient Preferred Name(optional)

This is the name our team will use to address you

Date of Birth

Gender Identity(optional)

Please describe your gender identity(optional)

Pronouns

Additional pronouns:(optional)

Please type in your pronouns if not included in the list above

Administrative Sex

This is necessary to submit claims to your insurance. Please provide the administrative sex on record with your insurance company.

Race

(you can select multiple)

Family Therapy Names and Ages

List the first and last names of additional family therapy participants, followed by their date of birth

Partner's Legal First Name

Partner's Legal Last Name

Partner's Preferred Name

Partner's Date of Birth(optional)

Partner's Gender Identity

Please describe your partner's gender identity

Partner's Pronouns

Additional pronouns:

Please type in your pronouns if not included in the list above

Partner's Administrative Sex

This is necessary to submit claims to your insurance. Please provide the administrative sex on record with your insurance company.

Partner's Race

(you can select multiple)

Name of person completing form or answering questions (if different from patient)(optional)

What is your relationship to the patient

Is the patient a legal adult

Will another adult be involved in scheduling, billing discussions, etc?

Does the patient require assistance setting up services and completing paperwork due to a medical condition?

Phone number for best contact

Text Message Opt-In(optional)

Please note that by checking this box, you are consenting to an occasional text message notification from MySpectrum LLC pertaining to scheduling or services. Messaging and data rates will apply. Messaging frequency may vary. Reminder messages for scheduling are sent twice over the course of a week. You may revoke this consent at any time by replying to text messages with "STOP". Read our Privacy Policy at https://myspectrumcc.com/privacy-policy/ and Terms and Conditions at https://myspectrumcc.com/terms-conditions/.

State

Please provide which state the patient will primarily be in during sessions. Sessions are teletherapy by default. In-person sessions can only be provided at our North Chesterfield, VA location and are dependent on availability.

City

Does your partner reside in a different state than you?(optional)

State

Please provide which state the patient will primarily be in during sessions. Sessions are teletherapy by default. In-person sessions can only be provided at our North Chesterfield, VA location and are dependent on availability.

Partner's Email Address

For couples counseling, both individuals will receive correspondence from our office.

Are you a first responder or the spouse or child of a first responder?(optional)

Whose insurance will be used?

Only one individual's insurance can be used. We are unable to bill couples therapy or family therapy to multiple individuals' insurance policies.

Check this box if you are getting free sessions through an EAP. EAP stands for employee assistance program, which is through your workplace.(optional)

Name of your EAP (ie- ComPsych, Cigna, Anthem, etc.,)

EAP Disclosure

A referral from your EAP to a specific clinician does not guarantee you will be scheduled with that therapist. EAP companies are not regularly aware of our therapist availability and occasionally provide guidance that is contradictory to our practice's scheduling process. Our schedulers will review your inquiry and check our available clinicians' expertise to confirm we have providers who meet your needs. If you wish to inquire about the availability of a specific clinician, please include that at the end of this form.

EAP Name

Other EAP Name(optional)

If you do not know the EAP name, please write your employer's name or the name of the service you believe is paying for sessions.

Curalinc Case Number

Insurance Provider of Prospective Client

Note: recent changes to Medicare's telemedicine coverage do not affect mental health services.

Tricare vs Veteran Affairs

If you have been referred to us by the Department of Veterans Affairs and they are covering your sessions, please go back and select "Optum Community Care through Veteran Affairs" instead of Tricare. Selecting Tricare when your coverage is through the VA will limit service options.

Some Virginia Premier policies are administered by Kaiser Permenante. If this is the case for your policy, please contact your insurance to secure a single-case-agreement before sessions. Otherwise, you may be responsible for out-of-network costs.

Write-in the name of your insurance provider if not listed in the drop-down above.

Do you have a secondary insurance or dual policy?(optional)

Secondary Insurance Provider of Prospective Client

Write-in the name of your secondary insurance provider if not listed in the drop-down above.

Check this box to acknowledge:

If you are using an insurance policy, you are responsible for knowing what mental health coverage that policy provides. If you want to know the cost of your sessions through insurance prior to scheduling or adding payment information to your chart, please contact the number on the back of your insurance card and ask them about your outpatient therapy benefits.

Check this box if this is a referral from Chesterfield CSA/FAPT(optional)

Please provide your Hanover CSA/FAPT Case Manager's first name

Please provide your Hanover CSA/FAPT Case Manager's last name

Please provide your Hanover CSA/FAPT Case Manager's contact information(optional)

Check this box if this is a referral from Hanover CSA/FAPT(optional)

Please provide your Hanover CSA/FAPT Case Manager's first name

Please provide your Hanover CSA/FAPT Case Manager's last name

Please provide your Hanover CSA/FAPT Case Manager's contact information(optional)

How did you hear about MySpectrum? (required)

Other:

QMHP Name(optional)

QMHP Email(optional)

Please add additional information for how you heard about MySpectrum here(optional)

Check this box if you are seeking therapy services related to a current or upcoming court case, legal matter, or legal requirement. (Examples may include DUI/DWI cases, custody or divorce proceedings, restraining orders, court-mandated therapy)(optional)

Please describe the legal matter, court case, or legal requirement for which you are seeking services.(optional)

Check this box if the patient is currently in foster care(optional)

Please attach the foster agreement at the bottom of this form submission. If you do not have the foster agreement, include the contact information for the foster care coordinator here:(optional)

Have you previously been a patient at MySpectrum Counseling and Coaching?(optional)

Would you like to schedule with the therapist you last saw or a new one?

Please describe what is bringing you to therapy today. (PLEASE NOTE - MySpectrum Counseling and Coaching does not provide diagnostic testing and does not provide medication management without a referral from a MySpectrum therapist.)

Self Describe Presenting Issue

Please describe what brings you to therapy in your own words.

If applicable, select up to 3 additional things you'd like to address with your therapist.(optional)

Do you anticipate needing disability leave or FMLA paperwork from your clinician?

Disability Leave / FMLA Disclosure

While some MySpectrum clinicians are able to complete disability leave or FMLA paperwork for patients, scheduling with one does not guarantee that they will fulfill this request. Please disclose whether you will require temporary/disability leave paperwork before scheduling by listing it in the presenting issues. The timeline and decision for completing this kind of paperwork will depend on the progress and outtakes of regular therapy sessions. Please check this box to acknowledge this information.

Scheduling Constraints(optional)

All of our therapists work different schedules. If you have any inflexible time constraints, please list them above. Fewer time constraints can lead to faster scheduling, so please only note those limitations that don't have room to change.

Please provide us with any other information that would be helpful as we match you with a therapist(optional)

If our team has questions for you before scheduling, when would be a good time to contact you?(optional)

Description

Please enter the details of your request. A member of our support staff will respond as soon as possible.

URL(optional)

Please attach images (front and back) of your insurance card below.(optional)

Form Completed By

Who is completing this form.

Staff Initials(optional)

utm source(optional)

utm source value

utm medium(optional)

utm medium value

utm campaign(optional)

utm campaign value

Attachments(optional)

Add file or drop files here