MENTAL HEALTH NEW CLIENT INQUIRY

I am in-network with Cigna and Highmark/ BCBS (not to be confused with Independence or IBX/ Blue Cross). For out of network coverage, you would be responsible for the full fee and I can provide monthly superbills so you can seek partial reimbursement from your insurance at the end of each month. Please include this information when scheduling an appointment.

For new clients please use the form below to inquire about starting as a new client. Please fill out all questions. I will respond within 48 business hours, Monday thru Friday.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Financials

Insurance ID

Provide ID if using insurance in-network

Please describe what attracted you to work with me and what you hope to get out of our time together.

Please tell me your availability for appointments and if you would like weekly or biweekly sessions.