WELCOME TO
Home
Services
Meet the Staff
Contact Us
Careers
Employee Portal
Common Questions
Links & Resources
Co-Payment
*
Indicates required field
Patients Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Telephone Number
*
Email Address
*
Patients birthday
*
Is the patient a minor?
*
Select One
Yes
No
If the patient is a minor, what is your relationship to the patient?
*
If the patient is a minor, are you legally authorized to give consent for psychological services for this child?
*
Select One
Yes
No
N/A
Is there a custody order?
*
Select One
Yes
No
N/A
Marital Status
*
Select One
Married
Single
Divorced
Separated
Widowed/Widower
Social Security number
*
Gender
*
Male
Female
With as much detail as possible, please explain the problem or the issue of concern.
*
Does the patient have insurance?
*
Yes
No
Name of the insurance company
*
Policy number
*
Does the patient have secondary insurance?
*
Secondary insurance policy number
*
Upload a copy of the front of your insurance card
*
Max file size: 20MB
Upload a copy of the back of your insurance card
*
Max file size: 20MB
Send Request
Home Page
Home
Services
Meet the Staff
Contact Us
Careers
Employee Portal
Common Questions
Links & Resources
Co-Payment