Couple's Counseling Registration Form

Requestor's Information

First Name

M.I.

Last Name

Contact Email Address

Phone Number

In case we need to reach you, how would you like us to contact you?

When is the best time to reach you?

Client's Information

Client's Mailing Address

City

State

Zip Code

Client's Gender

Client's DOB

Client's SSN

Client's Marital Status

Do you wish to provide Emergency Contact?

Emergency Contact Name

Phone Number

Relationship to Client

Spouse's / Partner's Information

First Name

M.I.

Last Name

Contact Email Address

Phone Number

Mailing Address

Appointment Scheduling

Reasons for seeking counseling (provide a brief description)

Appointment Preferences

Appointment Language Preference

Appointment Type Preference

Appointment Reminder Preference

Mobile Phone Number

Home Phone Number

Insurance Information

Will you be utilizing your medical insurance to pay for services?

Insurance Company Name

Subscriber's Name

Subscriber's DOB

Subscriber's SSN

Client Relationship to Subscriber

Subscriber's Employer

Mental Health Phone # (on back of ID Card)

Insurance Card ID#

Insurance Card Group Number

ID / Insurance Cards

In accordance with the government requirements to prevent medical insurance fraud, we require all of our clients to provide us with a copy of a state or federally issued personal identification document bearing a photo of the individual seeking services, such as driver’s license, state ID card or passport. We do not accept birth certificates or Social Security Numbers as proof of identify. Please note we are unable to schedule your first appointment without having received your ID card(s).

Would you like to upload your ID cards at this time?

Driver's License / State ID (FRONT)

Driver's License / State ID (BACK)

Insurance Card #1 (FRONT)

Insurance Card #1 (BACK)

Insurance Card #2 (FRONT)

Insurance Card #2 (BACK)

If you experience an issue uploading images of your ID cards, you may alternatively email us the photos of your cards to forms@vitacounseling.com.

YOUR REQUEST HAS BEEN SUBMITTED SUCCESSFULLY! WE WILL BE IN TOUCH SHORTLY TO SCHEDULE YOUR FIRST APPOINTMENT.

THERE WAS AN ISSUE WITH YOUR FORM SUBMISSION. PLEASE TRY AGAIN OR CALL US AT 855.826.8482. APOLOGIES FOR THE INCONVENIENCE THIS MAY HAVE CAUSED YOU

VITA Counseling Partners Online Client Registration

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Palmerton Office

Easton Office

Couple's Counseling Registration Form

Requestor's Information

Client's Information

Spouse's / Partner's Information

Appointment Scheduling

Insurance Information

ID / Insurance Cards

OUR MISSION:

OUR VISION:

USEFUL LINKS:

Registration Forms

Telehealth

Online Pay

Contact Us

OUR LOCATIONS:

Easton Office

3735 Easton-Nazareth Hwy, Suite 102

Easton, PA 18045

OUR LOCATIONS:

Palmerton Office

3295 Forest Inn Rd, Suite 3

Palmerton, PA 18071