Get treatment for all your mental healthcare needs. Connecting with us is 100% free, and 100% confidential. Fill out the following information, and someone from our team will be connecting with you soon! Name * First Name Last Name Date of birth * MM DD YYYY Phone * (###) ### #### State you are located? * How did you hear about us? * Do you currently have health insurance? Yes, Medicaid Yes, Medicare Yes, Tricare/TriWest/East Yes, Marketplace insurance Yes, through my employer/parent/spouse No, I am uninsured Insurance Info Insurance Provider examples UHC, UMR, BCBS, GEHA etc Member ID Connecting Preferred contact method? Phone Text Email Best Time To Connect? Morning Afternoon Evenings By submitting this information to DeltaPoint Wellness I am NOT committing to treatment care, I am submitting this information to help my professional advisor prepare for our welcome call. All information is kept private and confidential. The information provided will not be disclosed to any other party without written consent from the client directly. When scheduling a consultation call I understand that I will be asked to verify my personal information prior to any confidential information being discussed. * Yes Thank you!
