Self-assessment Form | Pathlight Mood & Anxiety Center

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I am reaching out...

For Me

For a Friend or Family Member

For a Patient

We're here to help when you need it.

Our licensed therapists welcome your questions. No obligation, no cost. We're here to help.

[The program] gave me the opportunity to explore my mental struggles when I needed it most. I felt safe, heard, and empowered.Taylor, Former Patient

The Basics

Relationship to patient

Your Information

Tell us about yourself:

First Name

Last Name

First Name

Last Name

Phone

Ok to leave a voicemail?

Yes

State

Type of Insurance

Program of Interest

Relationship to Policyholder

Condition

Please be advised that treatment coverage under Medicaid requires a Single Case Agreement (SCA). This is a special contract negotiated between ERC Pathlight and Medicaid for your specific treatment. While ERC Pathlight initiates this process on behalf of the patient, approval is determined by Medicaid.

Date of Birth

Enter date in MM/DD/YYYY format.

By entering in your telephone number, you agree to receive transactional SMS notifications and reminders from ERC and Pathlight via short code 73821. Message and data rates may apply. Message frequency may vary. You may receive alerts until you choose to opt out of this service by texting STOP to 73821 or replying STOP to any of our messages. Text HELP to 73821 for assistance.

Patient Information

Patient's First Name

Patient's Last Name

Patient Date of Birth

Enter date in MM/DD/YYYY format.

We're here to help when you need it.

The Basics

Your Information

Patient Information

Your experience