Please Fill out the form to have us verify your insurance benefits for mental health coverage. 

**Please note that we cannot bill hypnotism services through your insurance. Tele-therapy services may not be covered by your insurance and subject to a self-pay rate. We also cannot accept HMO plans. We’re deeply sorry for any inconvenience.**

Legal Name *
Legal Name
Use the name listed on your insurance card for verification reasons
Preferred Phone Number *
Preferred Phone Number
Please inform us of the name of your health insurance company.
This number is listed on the front of your insurance card. Include any letter prefixes from your member ID#.
Some insurance carriers request providers to call a specific phone number to verify your benefits. Including this phone number will expedite verification of benefits.
Date of Birth *
Date of Birth
Address on File with Insurance *
Address on File with Insurance
This is the address listed on your insurance plan.
Are you the primary insured on your insurance plan? *
If you are a dependent on your spouse or parent/guardian's insurance plan, the answer here is 'no'.
Name of Primary Insured
Name of Primary Insured
If you are not the primary insured, please fill out the information of the primary insured.
Date of Birth of Primary Insured
Date of Birth of Primary Insured
Parent, Spouse, etc.
Phone Number of Primary Insured
Phone Number of Primary Insured
Best day(s) of availability for sessions *
Best time(s) of availability for sessions *
Please clarify any information you feel is necessary to clarify for us and to determine which therapist is the best fit for you. This may include any goals or specifics on the best day and time to contact you.