Helping families heal and thrive through trauma‑informed care. Healing Families. Empowering Futures. One Life at a Time. Start Your Healing Journey Now Pre-Screening Δ Name(Required) First Middle Last Date of Birth:(Required) MM slash DD slash YYYY Gender:(Required)MaleFemaleMarital Status:(Required)SingleMarriedDomestic PartnerSeparatedDivorcedWidowedAddress(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mobile Phone:(Required)Home Phone(Required)Work Phone:(Required)Email(Required) Preferred Contact Method:(Required) Mobile Phone Home Phone Work Phone Email How were you referred to me?(Required)What are the main issues? Check all that apply:(Required) Anger Attention Difficulties Depression Anxiety Autism Spectrum Eating/Body image issues Other Please specify:Check all the following that are applicable:(Required) In therapy now In therapy in the past In the hospital now or recently Taken psychiatric medication in the past On psychiatric medication now Attempted suicide in the past None of the above What kind of care is being sought?(Required) Medication Psychotherapy Both Not sure Other - please specify Please specify:What medications are you taking?Dosage:Since when?Effective?Do you currently have an active insurance authorization for services?(Required) Yes No If yes, please provide your authorization number:We accept the following insurance plans: Medicare, Medi-Cal (California), Health Net Medi-Cal (California), and Medicaid (Texas) Will you be using one of the insurance plans listed above for services?(Required) Yes No If yes, Please indicate which plan:Primary InsurancePrimary Insurance Company:(Required)Member ID / Policy #(Required)Group Number:(Required)Client Relationship to Insured:(Required) Self Spouse Child Other Insured Name:(Required)Insured Phone #:(Required)Insured Date of Birth:(Required) MM slash DD slash YYYY Insured Gender:(Required) Male Female Insured Address:(Required) Street Address City State / Province / Region ZIP / Postal Code Insurance Verification & Authorization Disclaimer Submission of insurance information does not guarantee coverage or payment of services. All benefits are subject to eligibility verification, authorization approval (if required), and the specific terms of your individual insurance plan. Clients are responsible for confirming their coverage details, including co-pays, deductibles, service limitations, and authorization requirements. If authorization is required and not obtained or active at the time of service, the client may be financially responsible for services rendered. Wings of the Future will verify benefits as a courtesy; however, final responsibility for understanding and maintaining active coverage remains with the client.
