Teletherapy – Supportive Care

Telehealth

Telehealth Application

Until recently, Supportive Care exclusively provided behavioral health services in skilled nursing facilities, assisted living facilities and other similar settings. It now expanded its age bracket to include anyone over the age of 21 in response to increased feelings of isolation, depression, and anxiety resulting from the COVID-19 pandemic.

Supportive Care’s behavioral professionals are comprised of Licensed Clinical Psychologists, (PSYD), Licensed Clinical Social Workers, (LCSW), Psychiatrists, (MD), Nurse Practitioners (APRN), with expertise in psychological assessment evaluation and treatment, neuropsychological testing, medication management, and major psychotherapeutic modalities.

Our telehealth platform offers access to critical services to anyone over the age of 21 anywhere in the country. To schedule an appointment, please complete the form below.

Name*
First Last
Email*
Date of Birth
MM slash DD slash YYYY
Your Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Hidden
INSURANCE INFORMATION
Insurance Name
Your Member ID Number
Effective Date of Insurance
MM slash DD slash YYYY
Front and Back of Insurance Card
Max. file size: 100 MB.
CONSENT FOR ROUTINE DIAGNOSIS AND TREATMENT*
I accept
I consent for the Patient to receive counseling and psychotherapy services from Supportive Care. This consent allows the therapists to conduct, plan and direct my treatment; and follow-up amongst the multiple healthcare providers who may be involved in the treatment directly and indirectly. I fully understand that the results of the service(s) the Patient receives is (are) not guaranteed. Furthermore, I acknowledge that this consent will remain valid until I explicitly revoke it.
AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS*
I accept
I authorize Supportive Care, to bill and receive payments from the Patient’s healthcare provider or any other third-party payers (“Third-Party Payer”) that are applicable. I authorize the release of any medical or therapy information necessary to determine these benefits in order to process a claim. I permit a copy of this authorization to be used in the place of the original.
PRIVACY NOTICE*
I consent to the privacy policy
I understand that if I would like to review my records with Supportive Care, I have the right to request in writing a copy of the record. I understand that I may request in writing that you restrict how private information is used or disclosed to carry out treatment, payment or health care operations.
FINANCIAL RESPONSIBILITY*
I accept
I understand that I am ultimately responsible for the payment of bills for services provided to the Patient by Supportive Care. I understand that if Third-Party Payer does not pay or partially pays a bill from Supportive Care for any reason, I accept responsibility for the remaining balance and give Supportive Care of permission to directly bill me.
Credit Card Number
Expiration Date
Month
Day
Year
CVV
Name On Card
First Last
Billing Address
- Same As Above
Billing Address
Street Address City State ZIP Code
*
I certify that all the information provided is accurate and true.*

Telehealth

Telehealth Application

INSURANCE INFORMATION