To find out about your insurance eligibility please fill out the form below Check Insurance Eligibility Primary Policy Holder Name* First Last Email* Phone*Street Address*City*Zip code*Insurance PlanInsurance PhoneBirthdate of Primary Policy Holder* First Last ID NumberGroup NumberPatient Name* First Last Patient DOB* Date Format: MM slash DD slash YYYY Patients Diagnoses CodeUpload a copy of the front and back of your insurance card* Drop files here or I acknowledge that Connect Plus Therapy is an Out Of Network Provider. We require a minimum of ten hours of direct service per week. By signing this intake form you acknowledge that statement.*How did you hear about Connect Plus?*Please let us know who referred you, we would like to personally thank them.