If you plan to use insurance benefits to help you pay for your counseling this form MUST be completed 36 hours before your appointment. You must make an appointment with a therapist first.

Important Note:
Please complete the above form as accurately as possible. This will assist us in verifying your Insurance Benefit information. Please be sure to bring your insurance card AND Identification (i.e. driver’s license or passport) to your first appointment.

It is most important that you call your insurance company yourself to confirm what your benefits are specifically. A quote of benefits from your insurance company is never a guarantee of payment.

Your information is confidential and it is secured with us.