Name * First Name Last Name Date of Birth * MM DD YYYY Email * example@example.com Phone Number Please enter a valid phone number. (###) ### #### Primary Insured Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Insurance Company * Insurance Member ID# * Insurance Group Number Are you enrolled through a parent, spouse, or domestic partner? If yes, please provide the primary subscriber's name, date of birth and relationship with you. Thank you! You will hear back from us in less than 24 business hours via email! If you have any other questions, please send an email to us at inquiry@stridespsychotherapy.com Insurance Eligibility Check Form