New Patients

Insurance Verification Sheet

Fill out the sheet below and we'll verify your benefits before your first appointment. Every field is required except Notes.

B-Line Counseling / Jose Barrios

Give these numbers to your insurance carrier if they ask who the provider is.

Fields marked * are required.

Patient Information

Patient Name *

Date of Birth *

Phone Number *

Address *

Email *

Referral

Reason for Referral *

How You Heard About Us *

Insurance Information

Insurance Company *

Insurance Phone Number for Provider *

Member ID *

Notes

Notes (optional)

Rather not send this online? Call us at 201.267.0284 and we'll take your information by phone.