MENTAL HEALTH NEW CLIENT INQUIRY- FULL,

CURRENTLY WAITLISTING

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

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.

Where did you hear about me?