Guidepost Counseling for Wellness

Billing & Payment

Insurance card upload

Upload a photo of your insurance card

What is your plan for payment?

You can select more than one.

Insurance Cash pay Hoping for insurance but open to cash pay

If using insurance, who is your insurance provider?

Note: we are only in network with Partnership, some Blue Shield Plans, and Aetna.

What is the subscriber ID for your insurance?

may also be member ID. we do not need group number or other details.

How did you hear about us?

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Preferred clinician

Select a clinician from the list

Do you consent to the use of AI in the delivery of your care?

Your clinician may use AI tools (such as using AI to generate an intake summary) to help support your care. Your information is protected under HIPAA and anything generated by AI is always reviewed by your clinician. AI does not make decisions about your care. You can withdraw this consent at any time by contacting your provider without it impacting the care you receive.

Yes No

Reason for care

What are you looking for support with?

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.

Who would be receiving care?

Your info