EBT Intake
We will contact you in the order in which we receive these forms. If we currently have a waiting list you will be added accordingly.
Fill out the forms, email a copy of your driver’s license and the front and back of your insurance cards(s). You will be contacted as soon as there is an opening. If we don’t get a copy of both forms, your Drivers License, and insurance card (front and back) we cannot add you to the waiting list.
____________________________________________________________________________________
Please fill out BOTH forms below and email a copy of your ID and the front and back of your insurance card(s) to info@ebtherapy.org.
Once you click submit it will be routed to us in a Federal Privacy, HIPAA, and HITECH compliant format for processing.
We need all of this information (Client History, Intake Form, ID, and front and back of your Insurance card(s)) before scheduling an appointment. Thank you.
Our phone number is 865-280-2123 info@ebtherapy.org
To view the Complete Agreement follow this link.
***Email your ID and the front and back of your Insurance Card(s) to info@ebtherapy.org***
Contact Us
To become a new client or for more information, please fill out the form and we will contact you shortly. Please include your name, email, and phone number.