Good Faith Remote Care

First Name *

Last Name *

Date of birth *

Are you using any of the following to pay for your appointment? *

Medicare

Medicaid

Commercial Insurance (BCBS, Aetna, United Healthcare, etc.)

None of the above

Address

Street Address

City

State *

Country

Postal code

Phone *

Email *

Best Contact Method *

Email

Text

Call

Are you/is the person seeking counseling under the age of 18? If yes, please fill out the appropriate form that will populate below. *

Yes

No

Guardian Name

Guardian Date of Birth

Guardian Phone

Emergency Contact Info:

Emergency Contact *

Relationship to Patient *

Emergency Contact Phone Number *

By checking this box, I consent to receive transactional messages and calls related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

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