(281) 762-1663
info@renewedmindpllc.com
1000 Austin St, Suite D Richmond, TX 77469
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In Person and Telehealth Services in Texas ONLY
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First & Last Name
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First
Phone Number
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Email
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Are you seeking virtual or in-person services?
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Virtual Only
In-person Only
Hybrid (combination of virtual/in-person)
Service Type
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ADHD Evaluation (Comprehensive)
Autism Evaluation (Comprehensive)
Mental Health Evaluation (Comprehensive)
Immigration Evaluation
Adult/Individual Therapy (18+)
Children/Adolescent Therapy (9-12)
Teen Therapy (13-17)
Couples Therapy
Family Therapy (Max 4)
Group Therapy
Will you be utlizing insurance or EAP benefits?
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Yes-Insurance
Yes-EAP
No-Self Pay
If EAP, please identify your EAP provider
Aetna
Cigna
ComPsych
Corporate Counseling Associates (CCA)
Empathia/Life Matters
Health Advocates
Interface Behavioral Health
Lyra
Optum
Work Place Options
If EAP, please provide your referral/authorization # or code
Insurance Carrier
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N/A or Self Pay
Aetna
Ambetter
BCBS
Cigna
Community Health Choice
EAP
Medicaid/CHIPS
Superior
United Healthcare/Optum/UMR
Insurance # (OPTIONAL)
Group # (OPTIONAL)
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SMS Communication Consent
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By providing your phone number and submitting this form, you consent to receive SMS messages from Renewed Mind Counseling and Wellness related to appointment reminders, scheduling updates, billing notifications, service availability, and other practice-related communications. Message and data rates may apply. You can opt out of receiving text messages at any time by replying “STOP.” For more information, visit our Privacy Policy at https://renewedmindpllc.com/privacy-policy/
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