Get Started | Insight Wellness Center

The Intake Process

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1Brief Assessment
Answer a few questions about your preferences.

2Verify Payment Method
Get Pre-Authorized

3Match With A Professional
Free Consultation Request

Please share Information about yourself, preferences and requests. This will assist us in matching you with an appropriate provider/therapist.

Please select the service(s) that you would like us to assist you with*

Psychotherapy

Preop Eval (Bariatric, Kidney, Cancer)

Couples

Health & Wellness - Integrative Eval

Life Coach

Weight Loss Management Program

Grief Coach

CBD & Supplements Consultation

BrainTap

Mindfulness & Relaxation Training

EMDR

Love Language Counseling

Reiki

Other (Please Specify, group, etc..)

Other*

Demographic Information of Patient (Required, please be as complete and accurate as possible)

Name of Patient*

First Last

Address*

Street Address City State ZIP Code

Email*

Phone*

Alternate Phone Number

Who are the services for?

Date of Birth*

MM slash DD slash YYYY

Describe the reason you are seeking services today?.*

When did it start? How often does it happen? How does it affect your life? How have you dealt with it so far?

Have you ever experienced similar or other mental health symptoms before?*

If so, what was your experience like? When did it happen? Did you get help?

What else is important to know about you?*

Family History, Concerns, Medications

What would you like to accomplish?*

What is happening or is different? What stressors do you have? What do you hope will be different by seeking help?

Please check all that apply*

Anxiety

Depression

Grief/Loss

Hallucinations

OCD

Pain

Sleep

Physical or emotional abuse

Bipolar Disorder

Trauma (present or history)

Domestic Violence

Drug use or abuse

Eating disorder

Stress

Court appointment therapy

Alcohol abuse

Other

Other*

Do you have any thoughts of Suicidal Ideations? If you or someone you know is having any thoughts of suicide or self harm please go to your nearest emergency department. Call 911 or Suicide Hotline 988 or 1-800-273-8255.*

No Suicidal Ideations

Suicidal Ideations in the past. Non Present

Other

Have you experienced any psychiatric hospitalizations? If yes, please provide the date and reason.*

Physician's name (leave empty if none)

Psychiatrist’s name (leave empty if none)

Groups - Classes - Workshops - Education (Optional)

Grief Guidance Group

What's Your Love Language - Individual (International Mental Health Counselor)

Mindfulness Workshop

Other

Please indicate your preference for a male or female therapist, or select no preference*

No Preference

Female

Male

Who Referred You?*

We offer both in-office and telehealth sessions. If in-office is unavailable, are you open to telehealth instead? Please select your preference*

No Preference

Telehealth Preferred

In Office Preferred

Your method of payment will not be stored unless you decide to have services with Insight Wellness Centre.

Yes, I would like to subscribe to the newsletter.

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Select your payment method*

Health Insurance

Private Pay

Insurance and Billing Pre-Authorization Registration Form

Completing your preferred method of payment and insurance verification before your appointment expedites the registration process, ensuring you're seen faster and more efficiently.

Please complete all required fields. Once completed your information will be submitted securely and verified to ensure your insurance is accepted by the provider including coverage and benefit details. If your provider is Out-of-Network, claims will be submitted on your behalf, but you will be responsible for the full rate at time of service. Any payable benefits will be reimbursed to the subscriber of the plan. You will receive quote of benefits and rates via email confirmation from our Billing Manager, Victoria House [email protected] so that you know your account is ready for services with the provider you have been assigned.

Referred by / Assigned Therapist (Unknow if not yet assigned)

Demographic Information of Patient (Required, please be as complete and accurate as possible)

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Patient's Name*

First Last

Date

MM slash DD slash YYYY

Patient Date of Birth*

MM slash DD slash YYYY

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Address*

Street Address City State ZIP Code

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Phone*

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Other Phone(Optional)

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Email*

Insurance Carrier Name*

Medicare

UHC/UBH/UMR/Optum (no Medicare-type plans accepted)

Optum / Medicare (OON ONLY - Limited to scheduling availability

HealthNet/MHN

Kaiser (Referral authorization require)

Aetna (OON)

Anthem/BX (OON)

Contra Costa Health Plan

Tricare/HNFS

Centerstone (Authorization required)

Blue Shield CA/BXBS (OON)

Beacon (Chevron/PG&E/other-OON)

Other

"Other" Insurance Name

KAISER
In order to get your account confirmed for scheduling:
1) please conduct your intake phone interview with Veronica Penagos; she will assign a therapist to you.
2) Please request a referral authorization from your Kaiser PCP to your assigned provider and/or
3) complete this form with your Kaiser MRN# so we can put your on a future appointment hold so Kaiser can link you to this practice for retro-authorization.
NOTE You must complete a recent Kaiser clinical screening with a Kaiser clinical manager in order to proceed.

Insurance Cardholder Name

Cardholder's Date of Birth

MM slash DD slash YYYY

Policy Number

Group Number

Copay Amount

Deductible

Deductible Met?

Yes

Unsure (don't worry if you're not sure, this will be verified for you)

Relationship to Patient

Self

Spouse

Child

Date of Birth

MM slash DD slash YYYY

Do you have the image of you insurance card (if you select no please send copies to intake coordinator).

Yes

Please upload an image of your Insurance Card here (front and back):*

Accepted file types: jpg, png, pdf, Max. file size: 10 MB.

Image of Back of your Card*

Accepted file types: jpg, png, pdf, Max. file size: 10 MB.

Do you have Secondary Insurance (Include active plans)

Yes

Secondary Insurance Name

Secondary Insurance Cardholder's Name

Policy ID#

Date of Birth

MM slash DD slash YYYY

Upload an image of Secondary Plan ID Card (if not already attached above):*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

Do you have EAP Benefits?

Yes

Insurance Name (issuing your EAP Benefits)

EAP Auth#

Number of Sessions Auth'd

Auth Effective Date

Auth Expiration Date

We currently accept EAP referrals Optum EAP, please provide your auth# and number of sessions you have been approved for.

By Signing below, I agree to the following policies of Wellness Center's practice and services they provide:*

1) I authorize use of this form to convey my personal and insurance information to Insight Wellness Center
2) I authorize release of information to my insurance company for claims billing purposes.
3) I authorize insurance payments directly to the provider of service when they are considered a "Network Provider" or when my benefits allow it.
4) I understand I am responsible for the full amount of my bill for services provided. Cash, Check and Credit Card are accepted.
5) There is a 24-HOUR cancellation policy. I understand I will be billed IMMEDIATELY for the cash rate if I do not cancel at least 24 hours in advance of my appointment. Insurance does not cover no show/late cancellations; Missed session fee=$50 for Medicare plans and $100 for other insurance or Private Pay accounts.
6) In the event that my account goes unpaid for more than 90 days I acknowledge it may go to collections and I will be responsible for the balance due plus 30% collection fee.
7) Payment for services is ultimately my responsibility as insurance cannot be guaranteed.

I agree to these terms.

Signature of Responsible Party (use mouse or finger to sign)*

If an intake coordinator/representative completes

If an intake coordinator/representative completes this form on my behalf, I authorize them to sign with an 'X' on my behalf.

Name of Intake Representative Filling Out This Form*

First Last

Date Today*

MM slash DD slash YYYY

If someone else, besides the patient/responsible party

Check this box, if someone else, besides the patient/responsible party, is completing this form and is financially responsible for any balance due, please add your contact info here:

Name of Responsible Party if other than Patient named above*

First Last

Address*

Street Address City State ZIP Code

Phone*

Email*

Relationship with patient/client

Credit Card Authorization form

Please complete all required fields, including your credit card or checking account information. This is required to move forward with scheduling and ensures a smooth billing process. Your information will be securely submitted to our Billing Manager, Victoria House, and will only be used to create your StoredPay account. Once submitted, you will receive a separate confirmation email from [email protected] to authorize the use of your payment method for copays, deductibles, and private-pay balances per your rate agreement. ⚠️ Note: Your card will not be charged until services are rendered. However, submitting your payment method is required to verify financial responsibility and reserve your appointment.

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Name*

First Last

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Address*

Street Address City State ZIP Code

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Phone Number*

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Other Phone

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Email*

Select Credit Card or Account Checking Options:*

CREDIT CARD

ACCOUNT CHECKING

CREDIT CARD

Name as it appears on Card*

Card#*

Billing Zip Code for this Account*

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Account Number*

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Financial Responsibility & Release of Information Agreement (Signature Required)*

1) I authorize use of this form to convey my billing information to House Medical Billing Service; Victoria House, Billing Manager/Owner.
2) I authorize release of information to my insurance company (if applicable) for claims billing purposes.
3) I authorize insurance payments (if applicable) directly to the provider of service when they are considered a "Network Provider" or when my benefits allow it.
4) I understand I am responsible for the full amount of my bill for services provided. Cash, Check and Credit Card are accepted.
5) There is a 24-HOUR cancellation policy. I understand I will be billed IMMEDIATELY for the cash rate if I do not cancel at least 24 hours in advance of my appointment. Insurance does not cover no show/late cancellations; you will be expected to cover the amount insurance would pay or the normal rate you would pay for attending your appointment.
6) In the event that my account goes unpaid for more than 90 days I acknowledge it may go to collections and I will be responsible for the balance due plus 30% collection fee.
7) Payment for services is ultimately my responsibility as insurance cannot be guaranteed.

I agree to the above 1 to 7 policies of Insight Wellness Center's practice and services they provide

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Signature of Responsible Party (use mouse or finger to sign)*

ACCOUNT CHECKING

Bank Account Name

Routing Number*

Account Number*

Financial Responsibility & Release of Information Agreement (Signature Required)*

I agree to the above 1 to 7 policies of Insight Wellness Center's practice and services they provide

Signature of Responsible Party (use mouse or finger to sign)*

Check if you are filling this form on behalf of someone

Check if you are filling this form on behalf of someone else and you have the consent from the party in initiating this inquiry to sign on their behalf.

Full Name*

Phone*

Email*

Please direct any future billing questions to Victoria House, Billing Manager via email [email protected] Or Call (530) 474-6094

Free Appointment Consultation Request

We have included several ways to contact us. Please give us a call, send an email, or simply fill out the form on this page. We look forward to speaking with you.

Preferred Contact Method*

Schedule a Call

Connect via Email

Phone

Email Address

First Preferred Call Back Date

MM slash DD slash YYYY

Second Preferred Call Back Date

MM slash DD slash YYYY

Choose Your Preferred Callback Times (Select at least two)

09:00 AM - 10:00 AM

10:00 AM - 11:00 AM

11:00 AM - 12:00 PM

12:00 PM - 01:00 PM

01:00 PM - 02:00 PM

02:00 PM - 03:00 PM

03:00 PM - 04:00 PM

04:00 PM - 05:00 PM

05:00 PM - 06:00 PM

Is there any other information you would like us to know or specific contact instructions you prefer.

Feel free to provide a description of how we can assist you, avoiding overly detailed or highly sensitive information to ensure privacy. We will do our best to get back with you as soon as possible.

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