Client Portal - Pathways to Wellness

Appointment Request

Welcome to Pathways to Wellness! Please complete and submit the information below including your insurance information if you are intending to use your health insurance. Thank you for taking the first step in our work together!

Personal Information:

First Name:*

Middle Name:

Last Name:*

Date of Birth:*

Gender of Legal Record:*

Male Female

Contact Information

E-mail:*

Phone:*

Address

Address type:		Street Address:

City:		State:

Zip code:

Provider:

Please explain the reason you are seeking help at this time.

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

If you are experiencing a life threatening emergency please call 911. If this is a mental health crisis that cannot wait for a returned phone call, please call 1-800-273-8255.

Insurance:

Insurance Company Name:

Member #:

Submit

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Personal Information

Contact Information

Phone

Address

Provider:

Please explain the reason you are seeking help at this time:

Insurance