Intake Form

To begin the authorization process for services through insurance, please fill out the Intake Form below. Please contact our Admissions Team at admissions@rcsconsultingne.com or 508.650.5990 ext. 2008 with any further questions.

Insurance Intake Form

Insurance Information:

Patient's Name*

Patient's DOB*

Street Line*

Street Line 2

City*

State

Zip*

Country*

Insurance Provider*

Insurance ID #*

Group #

Insurance Phone # (Provider Services or Behavioral Health)*

Parent/Guardian Name*

Home Phone

Cell Phone*

Email*

Primary Diagnosis*

Secondary Diagnosis

Subscriber Name*

Subscriber DOB*

Employer*

State Insurance is issued*

Yes

Separator

Secondary Insurance (if applicable)

Do you have Secondary Insurance?*

Yes

Secondary Insurance Subscriber Name

Secondary Insurance Subscriber DOB

Secondary Insurance # and Group #

Splitter

Service Needs Information

Current School Hours*

Availability for Services:

Availability on Mondays*

Availability on Tuesdays*

Availability on Wednesdays*

Availability on Thursdays*

Availability on Fridays*

How many hours are desired per week?*

Other additional information

Intake Form

Insurance Information:

Secondary Insurance (if applicable)

Service Needs Information

Availability for Services:

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