Verify your Benefits:

Fill out the form below to receive an estimation of your insurance coverage.

*We cannot accept HMO insurances as we are not hospital affiliated. We apologize for any inconvenience. Check out our sliding scale and pro-bono options for alternatives!

**Insurance billing for treatment only available for the following insurance holders:

  • Aetna PPO

  • Alliance PPO

  • Allied Benefits Systems PPO

  • Beacon Health Systems PPO

  • Beacon Health Options (formerly ValueOptions) PPO

  • Blue Choice PPO

  • Blue Cross and Blue Shield PPO

  • Blue Cross Community

  • Cigna PPO

  • Humana Tricare

  • Humana Medicare

  • HealthPartners

  • Magellan Behavioral Health PPO

  • United Healthcare Optum PPO

 

Please complete the form below

First and Last Name *
First and Last Name
Date of Birth *
Date of Birth
Indicate an apartment or unit number for the street address, if possible, as well as the city and zip code. If your current address differs from your insurance carrier's recorded address, please record the address affiliated with your insurance carrier in the field below
Please record this information if it differs from your current address; Otherwise, leave this field blank if it is the same as your current address
Phone Number *
Phone Number
Please select your preferred method of contact
May we leave a message if we cannot reach you? *
We cannot accept HMO plans. Our sincerest apologies. Check out our pro-bono and sliding scale services for treatment options!
Include any letter prefixes
Primary Insured's First and Last Name (if you are a dependent)
Primary Insured's First and Last Name (if you are a dependent)
Primary Insured's Date of Birth (if you are a dependent)
Primary Insured's Date of Birth (if you are a dependent)
Primary Insured's Phone Number (if you are a dependent)
Primary Insured's Phone Number (if you are a dependent)
Please enter a brief description of why you are seeking treatment.
Please indicate your schedule on a given week that you are available for sessions. Indicate if you are free on weekdays, weekends, or certain times of the day (i.e., evenings on weekdays, Tu - Th from 10A - 4P). For those who have an inconsistent schedule, include up to two different weeks and time frames you will be free for an intake session and when you think you may have general times of availability for future sessions.