Self-assessment Form | Pathlight Mood & Anxiety Center

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Is this for you or someone else?

It's for Me

It's for a Friend or Family Member

I'm a Provider: For a Client/Patient

We're here to help when you need it.

Our licensed therapists welcome your questions. No obligation, no cost. We're here to help.

[The program] gave me the opportunity to explore my mental struggles when I needed it most. I felt safe, heard, and empowered.Taylor, Former Patient

Please provide the following information

Relationship to patient

First Name

Last Name

First Name

Last Name

Phone

SMS Confirmation

By checking this box, I agree to receive marketing and customer care SMS messages from Pathlight Mood & Anxiety Center at the number provided. Msg freq. varies. Msg & data rates may apply. Reply HELP for help. Reply STOP to opt out. Please see Privacy Policy.

Ok to leave a voicemail?

Yes

State

Desired Program Format

Condition

Date of Birth

Enter date in MM/DD/YYYY format.

Type of Insurance

Please be advised that treatment coverage under Medicaid requires a Single Case Agreement (SCA). This is a special contract negotiated between ERC Pathlight and Medicaid for your specific treatment. While ERC Pathlight initiates this process on behalf of the patient, approval is determined by Medicaid.

We do not currently accept this government insurance plan as a primary insurance in your state. Please contact your insurance company for assistance with seeking care at an in-network facility. Explore additional treatment options and resources that might be right for you on our insurance page.

Get help faster by sharing your insurance information (optional)

Insurance Company

Subscriber ID

Group #

I am the policy holder

Yes

Relationship to Policyholder

Subscriber Name

Subscriber DOB

Patient Information

Patient's First Name

Patient's Last Name

Patient Date of Birth

Enter date in MM/DD/YYYY format.

We're here to help when you need it.

Your Information

Patient Information