Prospective Patient Form

Our admissions process begins with a comprehensive assessment of each patient’s medical, psychological and sociocultural history, as well as thorough verification of insurance benefits. Together with guidance from the Clinical Assessment team, this information helps patients and families make informed decisions about pursuing and financing eating disorder treatment.

Please complete the form below to provide your information to our Clinical Assessment team. By submitting this information, you are consenting to have a clinical team member follow up with you as well as have our business office check your insurance benefits.

Prospective Patient Form

Your Information

Person Completing This Form

First Name

Last Name

Date of Birth

Enter date in the YYYY-MM-DD fomat.

Best Phone

Phone Type

By entering in your telephone number, you agree to receive transactional SMS notifications and reminders from ERC and Pathlight via short code 73821. Message and data rates may apply. Message frequency may vary. You may receive alerts until you choose to opt out of this service by texting STOP to 73821 or replying STOP to any of our messages. Text HELP to 73821 for assistance.

Address

City/Town

State

ZIP Code

Preferred Method of Contact

Is there a method we cannot use?

Treatment Information

Location of Interest

Desired level of care

Condition

Insurance Information

Type of Insurance

If you have government insurance (Medicare/Medicaid/Tricare), we first need to speak with the case manager at your insurance company. Rather than completing this form, please have your case manager contact us at 1-877-920-2902.
Learn about additional treatment options and resources that you may be eligible for here.

If you are not currently insured, please learn about additional treatment options and resources that you may be eligible for here rather than submitting this form, or call us at 877-825-8584.

Insurer

Insurance Contact Phone Number

ID/Account Number

Group Number/Account Number

Name of Policyholder

Relationship to Patient

Policyholder Date of Birth

Enter date in the YYYY-MM-DD fomat.

Name of Policyholder's Employer

To whom do you want to communicate insurance information

Name

Phone

Current Treatment Team Information

Therapist Name

Family Therapist

Psychiatrist

Primary Care Physician

Other Outpatient Team Members

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Prospective Patient Form