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Application for Mental Health Counselor

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ONLINE REGISTRATION FORM

Congratulations on taking the first step toward enlightenment and healing! Love Light Mental Health Counseling Services, PLLC would LOVE to assist you with attracting more LIGHT to your life!

Please take a moment to fill out this form, allowing us to gather additional information about the purpose of your therapy request. This information is crucial for both beginning the registration process and confirming your eligibility for insurance coverage, should you choose to utilize insurance. Once we receive your submission, a dedicated member of our registration team will reach out to you with the necessary next steps.

Please call 911 or go to your nearest urgent care or emergency room if you or someone you know is experiencing an imminent mental health crisis. Your safety and well-being are of utmost importance.

Email *

Name of person filling out this form *

What is your relationship to the person seeking therapy? *

Therapy Across State Lines

Please be advised that your therapist must be licensed in the state that you live in. Love Light currently provides therapy to persons who live in New York and New Jersey.

What state are you seeking therapy in? *

New York (NY)

New Jersey (NJ)

Client's Legal First Name *

Client's Legal Last Name *

Client's Date of Birth *

Client's Gender *

Female

Male

Non-Binary

Prefer not to say

Client's Mailing Address (include apt no. if applicable) *

State *

City *

Zip *

Client's Phone Number *

Client's Email Address (primary) *

PHOTO ID UPLOAD - FRONT
Please upload a copy of the FRONT of your photo ID. Your photo ID is required in order to verify your insurance benefits during your eligibility & benefit check and your identity during the first session.

*

PHOTO ID UPLOAD - BACK
Please upload a copy of the BACK of your photo ID. Your photo ID is required in order to verify your insurance benefits during your eligibility & benefit check and your identity during the first session.

*

Have you been to therapy before? *

Yes

No

Please tell us briefly a little bit about your reason(s) for therapy. *

Please select your PRIMARY INSURANCE from this list. *

Aetna

Cigna Evernoth

1199 SEIU National Benefit Fund

Anthem - Empire Blue Cross Blue Shield - New York (This is not NYSHIP/The Empire Plan)

Anthem - Other Blue Cross Blue Shield Plans (This is not NYSHIP/The Empire Plan)

NYSHIP/The Empire Plan (We are NOT in network with NYSHIP/The Empire Plan, Select OON or OPT OUT below)

OPTUM/ United Healthcare

Oscar Health/ Oscar Small Group/ Oscar Circle Plus

Oxford Health Plans

UMR

UBH General

Magnacare Network

I have an insurance plan that is NOT listed above and so, I plan to use my out-of-network benefits (OON)

I have insurance but I do not wish to use my insurance, and plan to pay out of pocket instead (OPT OUT).

I do not have insurance. I plan to pay out of pocket (OOP).

Please provide your primary insurance member ID.
Write N/A if you are not using insurance.

*

Please provide your primary insurance Group Number.
Write N/A if you are not using insurance.*

*

Full Name of primary insurance policy holder if different from above.

1). IF YOU ARE USING INSURANCE, PLEASE PROVIDE THE POLICY HOLDER'S NAME. Failure to do so will delay the registration process.
2). Write N/A if the client is the policy holder*

*

Date of Birth of primary insurance policy holder

*

Do you have a SECONDARY insurance policy?

*

Yes

No

Are you using an Employee Assistance Program (EAP)? *

Yes

No

If yes, please provide the EAP code provided to you by the insurance company.
Write N/A if this does not apply to you.

*

How many free sessions do you get with your EAP authorization code? *

Please provide the following:

1). Name of SECONDARY insurance company
2). Member ID of SECONDARY insurance policy
3). Name of policy holder of SECONDARY insurance policy
4). DOB of policy holder of SECONDARY insurance policy

Write N/A if this does not apply to you.*

*

INSURANCE CARD UPLOAD - FRONT
Please upload a copy of the FRONT of your insurance card. Your insurance card is required in order to verify your insurance benefits during your eligibility & benefit check and your identity during the first session.

*

INSURANCE CARD UPLOAD - BACK
Please upload a copy of the BACK of your insurance card. Your insurance card is required in order to verify your insurance benefits during your eligibility & benefit check and your identity during the first session.

*

EAP LETTER UPLOADPlease upload a copy of your EAP Letter with the authorization code and effective date. Please note that if you have an EAP that you would like to use, you must upload the supporting documents in order to receive your free sessions.

Standard Therapy is a recurring WEEKLY appointment. We offer appointments Sunday-Saturday, 9am-9pm, depending on the therapist.

What is your availability for weekly recurring appointments? Choose all that apply. Please give at least 3 options.
*

Mon-Fri Mornings (9am-12pm)

Mon-Fri Afternoons (12pm-5pm)

Mon-Fri Evenings (5pm-9pm)

Sat-Sun Mornings (9am-12pm)

Sat-Sun Afternoons (12pm-5pm)

Sat-Sun Evenings (5pm-9pm)

Do you have any other preferences for a therapist? If so, please share with us. We will try to accommodate as best as we can.

Couples or Family Therapy

Please provide the following information if you are seeking Couples or Family Therapy.
Write N/A if these do not apply to you.*

FIRST and LAST NAME of your partner or family member if you are seeking Couples or Family Therapy.
Write N/A if this does not apply to you.*

*

Mailing Address of your partner or family member if you are seeking Couples or Family Therapy.
Write N/A if this does not apply to you.*

*

Phone Number of your partner or family member if you are seeking Couples or Family Therapy.
Write N/A if this does not apply to you.*

*

Email address of your partner or family member if you are seeking Couples or Family Therapy.
Write N/A if this does not apply to you.*

*

May we EMAIL you regarding your therapy inquiry? *

May we CALL you regarding your therapy inquiry? *

May we TEXT you regarding your therapy inquiry? *

Which is your preferred method of contact? *

Email

Phone Call

Text

Please share any additional information that you may want to share that you have not already shared with us.
Write N/A if you do not have any additional comments.*

*

How did you hear about us? *

Thank you for filling out this Registration Form!

Here's what to expect next:

Our Administrative Assistant will reach out to you within 4 business days to discuss the next steps. They'll guide you through the registration process and match you with a therapist who suits your preferences, as best as we can. Our office hours include Tuesdays-Fridays 9am-5:00pm.

Please also verify your insurance benefits with your insurance company as inaccurate information is sometimes relayed to us. Please note that there is no way for us to know your exact benefits until we submit and receive back the first claim.

Once everything is set, you'll have the first session with your therapist in which they will obtain further information from you to help create a plan to achieve your therapy goals and start on your journey towards growth and healing!

For any questions or concerns, feel free to reach out to us at hello@loveandlightpsychotherapy.com. We are here to support you at every step of your journey. Thank you for considering our services. We look forward to assisting you on your path to positive change and growth!

Kind Regards,
The Love Light Team

ONLINE REGISTRATION FORM

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