Inquiries

Thank you for reaching out to us regarding our online services. Please complete the following information below and attach the requested documents. Once all information is received, we will be reaching out to you within 1 to 2 business days to schedule your first appointment.
Client's Name
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Address
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- Street Address
- Address Line 2
- City
- State / Province / Region
- Postal / Zip Code
- Country
Guardian's Name if under 18
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DOB
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Phone Number
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Email Address
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Referred By (Pediatrian, DHR, Children's of AL, Friend Psychology Today, etc)
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Brief description of reason for counseling.* N/A is not acceptable*
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Insurance/Payment Type
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1878
Medicaid
BCBS
VIVA
AllKids
Cigna

Cigna EAP
NDBH EAP
Morneau Shepell EAP
United Health
TriCare
Anthem BCBS
Complete Insurance Policy Number Primary *N/A is not acceptable* In accurate information can cause a delay in scheduling.
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Secondary Insurance Company and Number
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Other Mental Health Provider
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You are responsible for contacting your insurance company and obtaining your copayment for mental health services. If you DO NOT provide the accurate information or fail to contact your provider prior to your first appointment, you will be charged the full session amount of $125.00 You can provide the following information to retrieve the information needed. Provider Monique Johnson NPI # 1003105321
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If the insurance is through EAP, you will need to have your provider fax over or email the authorization form/code to 205-278-5526/info@rcsbham.com
Please send a copy of the front and back of your insurance card and your driver's license to info@rcsbham.com. Once you receive an invitation to the client portal, please have your intake completed before your first appointment. NOTE: If the form is not completed accurately in it's entirety, it will delay your intake process.* Thank you in advance for allowing us to serve you!
*Additional Information you may want to provide*
What County and State Do You Reside In?
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