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 *
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: *
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:
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.