Lotus Counseling Services, PLLC

Lotus Counseling Services, PLLC Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Date of birth

State

Select the state you live in

Are voicemails okay?

Yes No

Are text messages okay?

Yes No

Billing & Payment

How do you plan to pay for services?

If using insurance, please upload your insurance card below. This allows us to verify your insurance benefits and provide you with a cost estimate.

Insurance EAP - if using EAP, we will reach out for more details Private pay ($150/session)

Insurance card upload

Upload a photo of your insurance card

What is your relation to the primary insured?

I am the primary insured. My spouse is the primary insured. My parent is the primary insured. I am not using insurance.

What is the name of the primary insured? (REQUIRED to bill insurance)

What is the date of birth of the primary insured? (REQUIRED to bill insurance)

Do you have another insurance policy?

If you have more than one insurance policy, we will reach out to you via email to collect the additional information. It is important that you tell us if you have another policy, even if you do not plan to use it.

Yes, I have another insurance policy. No, I do not have another insurance policy. I am not using insurance.

Administrative

Driver's license upload

Do not upload sensitive financial information such as credit card information.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.