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Start care with Behavioral Health Associates of Hawaii.
Verify Insurance
Full Name
First
Last
Phone Number
Do You Agree to Receive Communications via Text Message*?
Yes
No
Email
Date Of Birth
MM slash DD slash YYYY
Are you seeking treatment for yourself or someone else?
Myself
Someone else
What can we help with? Check all that apply:
Anxiety
Depression
Trauma / PTSD
Addiction
Grief
Relationships
Other
Name
(Required)
First
Last
Relationship to Patient
Parent
Spouse
Partner
Insurance Information
Please provide as much of your insurance plan information as possible. We may speak with you in order to fully verify your coverage.
Subscriber/Policyholder Name
Subscriber Date of Birth
MM slash DD slash YYYY
Insurance Provider Name
Subscriber ID or Member Number
Preferred Level of Care (check all that apply)
I’m open to whatever!
Group Therapy 2-3 days / week (Faster healing, Best for Insurance)
Summer Intensive Program (Talk to Staff before checking this one)
1x/week Therapy for Individual or Couple (OP)
Primary Service Type (Check all that apply):
Mental Health – Adult
Mental Health – Adolescent
Substance Abuse – Adult
Substance Abuse – Adolescent
Eating Disorder – Adult
Eating Disorder – Adolescent
Additional information
*By checking Yes, you agree to receive informational messages, appointment reminders, confirmations, and customer care/account notifications from Turning Point Mental Health, LLC
