Client Information

Welcome to this client information page.

Please fill out the form below to share your insurance information with us in order to find out what your benefits are.

Kindly provide the following information allowing us to look up your insurance details and inform you what to expect for billing. Please call 951-923-4350 if you have any questions, or if you prefer to share this information via phone. Thank you!

Do you have insurance?*
We will look up your benefits and take care of all the paperwork if you decide to visit
Name*
First Last
Phone*
Email*
Preferred Method of Contact*
Preferred Time of Day for Contact*
Check This Box if We Already Have All Your Insurance Information
- You already have my insurance information on file- I just have a question about a new service. Please contact me.
Date Of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Address on file with insurance company (if different from above)
Street Address Address Line 2 City State ZIP Code
Insurance phone number (located on the back of the insurance card)*
Insurance company*
Member ID (not group number)*
What services interest you?*
- Individual Therapy
- Couples Therapy
- Online Group Therapy
How did you hear of Happier Healthier Productive?*
If you were referred by a friend or doctor, please let us know who referred you so that we may thank them.
By signing my name below, I hereby give Happier Healthier Productive permission to look up my insurance benefits and relay them to me.*

Welcome to this client information page.

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