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

**Please note that we cannot bill massage, tele-therapy, or hypnotism services through your insurance plan. We also cannot accept HMO plans. We’re deeply sorry for any inconvenience.**

Name *
Name
Please inform us of the name of your health insurance company.
This number is listed on the front of your insurance card.
Date of birth: *
Date of birth:
Address: *
Address:
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.
Phone number of primary insured:
Phone number of primary insured:
Date of birth of primary insured:
Date of birth of primary insured: