RCTC - Demographic/Financial Information Demographic/Financial InformationThank you for your inquiry regarding Zumbro Valley Health Center Psychotherapy through RCTC. Psychotherapy services are typically covered through health insurance companies. To get started in services, please complete the following form call Zumbro Valley Health Center’s main office at 507-289-2089 and request intake.Name* First Last Date of Birth* MM slash DD slash YYYY Social Security # Address Street Address City State / Province / Region ZIP / Postal Code County of Residence Annual Household Income Number of Persons in Household Individuals Under 18 in Household Parent Name or Contact Person* First Last Phone Number of Contact Person*Insurance Carrier & ID Number* Cardholder's Name* First Last Cardholder's Date of Birth* MM slash DD slash YYYY Secondary Insurance Carrier & ID Number (if applicable) Secondary Cardholder's Name First Last Secondary Cardholder's Date of Birth MM slash DD slash YYYY HiddenEmail PhoneThis field is for validation purposes and should be left unchanged.
