Foresight Appointment Request Form 2026

Welcome To Foresight!
We're so glad you're here. We're excited to have the opportunity to support you on your path to well-being.

By completing the form below, you agree to be automatically booked for your requested appointment services. You will need your insurance information to complete this form.

To ensure that the appropriate individual receives the necessary care, please provide their specific information if you are completing this form on their behalf.

Contact Information
Name*

First NameLast Name
Preferred Name
What are your pronouns
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Birthday*

MonthDayYear
Date
What is your gender identity?*
less-than-18*

I understand that a copy of any existing custody agreement must be submitted before scheduling can take place. Foresight holds no liability for any undisclosed custody agreements
more-than-18*

I understand that not all Foresight providers are enrolled with Medicare. I also understand that when I am enrolled, or enroll in the future with medicare or a medicare advantage plan, it is my responsibility to report that information to Foresight so that my plan may be verified to determine if services will be covered. Any visits not covered by my insurance plan will be my financial responsibility.
Sex (as listed on insurance policy)*
Address*

Street Address

Street Address Line 2

City

Zip Code
State*
Services are available only in the states shown in the dropdown menu above. Please note: You MUST be in the state you are receiving services for all appointments.

Insurance Information
If available in your area, are you interested in being seen in-person at one of our offices? If there is no in-person availability in your area, you will be booked for virtual sessions.*

YesNo
Insurance Provider*
Authorization #*
Authorization Start Date*

MonthDayYear
Date
Authorization End Date*

MonthDayYear
Date
University
Name Of Insurance Provider*
Subscriber ID*
Please upload a copy of the front and back of your insurance card here*

Cancelof
I understand that having insurance information may be required for scheduling.*
Understand that having insurance information may be required for scheduling.
Are you the primary subscriber of this insurance policy?*

YesNo
Primary Subscribers Name*
Primary Subscribers Date of Birth

MonthDayYear
Date

Welcome To Foresight!