Name *

First Name

Last Name

Phone

(###)

###

####

Please understand that while we verify that your insurance is active, it is your responsibility as the insurance policy holder to know the benefits of the plan you carry. The best way to confirm any benefit is to call your insurance company and ask what your mental health benefits are and who is in your network. *

Yes, I understand.

No, I don't get it.

Are you utilizing EAP benefits? *

This must be declared at the time of scheduling because we do not participate in all EAP programs.

Yes

No