Skip to main content
facebook
linkedin
Call Us: (713) 425-4248
Hit enter to search or ESC to close
Close Search
Menu
Home
Services
Locations
Careers
Resources
Contact Us
Verify My Benefits
Verify Benefits
First and Last Name of Client
*
Client Date of Birth
Client Gender
-None-
Male
Female
Current Insurance
Known Allergies
Previous Therapy History
Primary Care Physician
Behaviors of Concern
Copy of insurance (front/back)
File(s) size limit is 20MB.
Guardian First Name
*
Guardian Last Name
*
Guardian's Email
*
Mailing Street
Other Street
Mailing City
Mailing State
Mailing Zip
Guardian's Mobile
Guardian's Work Phone
*
Guardian's Home Phone
*
Close Menu
Home
Services
Locations
Careers
Resources
Contact Us
Verify My Benefits
facebook
linkedin