Higher Sights

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Will you be in the state of Colorado when attending appointments?

Yes
No

What Is The Client’s Legal First And Last Name (As Listed with Insurance)?

First Name

Last Name

What is the contact email address?

Email Address

What is the client’s date of birth?

Date of birth

Are You a Current or Previous Client?

Yes
No

Are you looking to use insurance for services?

Yes
No

What is the client’s primary insurance member ID number?

Insurance Member ID

Do you have a secondary insurance plan?

Yes
No

What is the member ID for the client’s secondary insurance plan?

Member ID

First biological legal guardian's first and last name, email address, and phone number

Primary Legal Guardian’s Full Name

Primary Legal Guardian’s Email

Primary Legal Guardian’s Phone Number

Second biological legal guardians first and last name, email address, and phone number?

Secondary Legal Guardian’s Full Name

Secondary Legal Guardian’s Email

Secondary Legal Guardian’s Phone Number

Any other legal guardians (with medical decision making) first and last name, email address, and phone number?

Other Legal Guardian’s Full Name

Other Legal Guardian’s Email

Other Legal Guardian’s Phone Number

How did you hear about us?

Psychology Today
Google Search
Mental Health Match
Current Higher Sights Provider
Current Higher Sights Client
Instagram
FaceBook
Other