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Appointment Type
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Teletherapy
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Please check the box indicating your preferred method of payment, check all boxes that apply
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Is your insurance a "PPO"?
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(This means that we can see you regardless of whether our practice accepts your insurance or not.)
Please see your insurance card for the following question, Do you have a deductible
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If yes, how much is it?
$500
$1,000
$1,500
Has your deductible been met this year already?
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Not Sure
I am available to make an appointment on: (check all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
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Can you make early morning weekday sessions? If yes, beginning at
7am
8am
9am
Can you make weekend appointments? If yes
Only Saturday
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Either day could work
Therapist Preference
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Female Therapist
Male Therapist
First Available
No Preference
Preferred Appointment Time
Morning
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Can you make weekday appointments that begin from 10am-3pm?
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Yes
No
Our private pay rate is $165. On a limited basis we can consider a reduction in rate of between 10-25% depending on circumstances. If insurance coverage is not available or desirable to you, can you pursue private pay care?
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