IMPORTANT**- Our team has experienced a large influx of referrals the last few weeks and If you've made it to this form , please know that it may be a few weeks before you receive a response.

Thank you for your interest in working with a Rose Wellness Therapist!

Privately Paying Clients-We accept those that are privately paying for services. Those that choose to go out of network will receive a "superbill" that they can submit for potential reimbursement to their insurance.

If you are looking to go through your insurance please read the following information.

Insurance- We are in network with the following:

Cigna (All therapists)
Cencal (All therapists)
Healthnet medi-cal (All therapists)
Anthem UCSHIP (All therapists)
Regular Anthem plans- (Associates and Licensed- limited availability at this time)
Aetna (All therapists)
Cal Viva (All therapists)
CA health and wellness (All therapists)
Heathnet/MHN commercial (Licensed Only)
United Healthcare/ Optum UBH (All therapists)

Your responses will be stored in our HIPAA compliant and private platform and reviewed by our intake specialists. Please fill this form out in our entirety so that we can match you with the therapist that would be the best fit for you!

Are you Requesting Services for yourself, or someone else? *

Your Name (person filling out this form)

Your email (person filling out form)

Your phone number (person filling out form)

How did you hear about us? *

What type of therapy services are you requesting? *Please check all that apply

Client Information

-Please enter the information for the person you are requesting services for

-If requesting services for yourself, fill out with your information

Client's Full Legal Name *

First, Last

Clients Preferred Name *

Client's date of birth (DOB) *

Client's Gender *

Client's Phone Number *

Or primary contact phone # if filling out for a minor

I consent to receiving text messages from Rose Wellness at this phone # regarding my inquiry and availability. *

Yes

You can text STOP to unsubscribe at anytime

Client's Email *

Or primary contact email if filling out for a minor

Client's Age *

____ Years old

Does the client identify as transgender? *

Client's Pronouns *

Ex: She/Her

Client's Current Address *

Client's Preferred Language *

Your Partner's Name (First and Last)

Your Partner's Date of Birth

Partner's gender

Your Partner's phone number

Your Partner's email address

Teen's email address

We use this to send assessments to track your teen's progress in therapy!

Therapy Preferences

What would you (or the person you're requesting services for) like to work on in therapy? *

Are you requesting to work with a particular therapist? *

Which therapist(s) were you hoping to work with?

What are you (or the person you're requesting services for) looking for in a therapist? *

Let us know if you've had any previous successful therapy and what made it successful.

Are you interested in any of our group offerings?

Client Location Preference *

Please let us know if you have a preference for telehealth or in person

Are either you or anyone you're requesting services for experiencing thoughts or desires to harm themselves or others? *

Please describe any more details or history you feel comfortable sharing re; suicidal ideation, self harm and/or desire to harm others

Are you or anyone you're requesting services for concerned with their substance use? *

Please describe concerns with substance use below

Availability for Regular Appointments

Client's current availability for ongoing weekly sessions? *

Other info regarding availability

Guardian Information (Skip if client is over 18)

If client is under 18 years of age, enter guardian information below.

Custody Status *

Please describe custody/ guardianship arrangement if selected other

Does your teen/ child have more than one guardian?

Guardian 1 Date of Birth *

Does guardian 1 have legal custody of the client? *

Guardian 2 Date of Birth *

Guardian 2 Phone Number *

Does Guardian 2 have legal custody of this client? *

Insurance Information

Primary Insurance (Skip if N/A or not using insurance)

If filling out for a minor- please put their insurance coverage here

Once you are scheduled for a consultation with a therapist, we will check your benefits with your insurance. Verification of benefits is a courtesy and not a guarantee of coverage. If your insurance does not cover services, you will be responsible for the amount owed each session. It is important for you to be proactive in knowing your insurance benefits. We encourage you to call your insurance representative using the member service number on the back of your card to verify this information for yourself. The insurance payor has final say on claims submitted on your behalf including any copay, coinsurance, or deductible amounts that may be owed.

Do you have Insurance? *

If filling out for a minor put their insurance coverage here

Are you requesting to use EAP benefits at this time? *

What is your EAP carrier?

Cigna EAP

Healthnet EAP

Optum EAP

What is your EAP authorization code/ Referral #?

Who is your Primary Insurance Carrier? *

Who is your primary insurance under (if you selected other)

Client's relationship to primary subscriber on this plan (primary insurance) *

Primary Subscriber (First and Last Name) Primary Plan *

Primary Subscriber's Date of Birth (primary insurance) *

Primary Insurance Member ID *

Upload Front of Primary Insurance Card *

Click upload button first, do not drag and drop

Upload Back of Primary Insurance Card *

Click upload button first, do not drag and drop

Upload Driver's License of Client

Recommended

Secondary Insurance Info (Skip if N/A or not using insurance)

Who is your Secondary Insurance Carrier? *

Insurance Carrier if you selected other (Secondary)

Client's relationship to primary subscriber (secondary plan) *

Secondary Insurance Member ID *

Primary Subscriber's First and Last Name (Secondary plan) *

Primary Subscriber's DOB (Secondary Plan) *

Upload Front of Secondary Insurance Card *

Upload if you have secondary insurance

Upload Back of Secondary Insurance Card *

Upload if you have secondary insurance

CAPS Anthem UCSHIP Student Referral

If you don't have a CAPS referral yet, please continue to submit form and reach out to - [email protected] to request one. Once received you can email it to [email protected]. The sooner we have this the more quickly we can get you services!

Please upload your EAP authorization letter (if you have one)