Assessment Sign Up Please enable JavaScript in your browser to complete this form.First Name *Last Name *Phone *Email *Appointment Reminders *YesNoWe offer both text and voice reminders for your appointments. Do you grant Belair Clinic permission to send you reminders about your upcoming appointments to the phone number provided?Sex *MaleFemaleXPrefer not to respondDate of Birth *mm/dd/yyyyProbation officer If you have a probation officer, please include their name, phone number, fax number, and which court they are affiliated with. If you are not on probation, just type N/A.LawyerIf you have a lawyer, please include their name, phone number, fax number, and which firm they are affiliated with. If you are not seeking an assessment due to legal concerns, just type N/A. Have you had any previous counseling? If you've had previous counseling, please include it here--including dates of service and name of facility or counselor.Payment Method (Insurance) *CashKaiserPremeraLifeWiseFirst ChiceUnitedOtherWe are currently only in network with the private insurance companies listed below. We are not in network with any state insurance such as AppleHealth, Molina, etc. If you have any questions please give us a call.Insurance Member ID# Insurance Group Number This is required for those insured with LifeWise Please briefly explain why you are seeking counseling services * *Submit
