EBT Intake
I will contact you in the order in which I receive these forms. If I currently have a waiting list you will be added accordingly.
Fill out the forms, email a copy of your driver’s license and the front and back of your insurance cards(s). You will be contacted as soon as there is an opening. If we don’t get a copy of both forms, your Drivers License, and insurance card (front and back) we cannot add you to the waiting list.
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Please fill out BOTH forms below and email a copy of your ID and the front and back of your insurance card(s).
Once you click submit it will be routed to me in a Federal Privacy and HIPAA compliant format for processing.
I need all of this information (Client History, Intake Form, ID, and front and back of your Insurance card(s) before scheduling an appointment. Thank you.
Our phone number is 865-851-1414 info@ebtherapy.org
To view the Complete Agreement follow this link.
***Email your ID and the front and back of your Insurance Card(s) to info@ebtherapy.org***
Contact Us
To become a new client or for more information, please fill out the form and we will contact you shortly. Please include your name, email, and phone number.