Name *

First Name

Last Name

Phone *

(###)

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How do you plan to pay?

We work with most insurance carriers as out-of-network (OON) providers. We ask that you pay the session fee after each session. Subsequently, we will submit your claims to your insurance company on your behalf. If you have OON benefits, your insurance company may reimburse you a portion of the fee.

Self-pay (out-of-pocket)

Insurance (pay upfront, we submit your claim to your insurance)

Date of Birth (D.O.B.)

To streamline the process, we can check your out-of-network insurance benefits, using your D.O.B. & insurance card

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DD

YYYY