Printer Friendly Version

We are happy to provide the benefit of filing Primary Insurance only for our clients. The following must be completed 5 days prior to your first session. If the form is not completed you may be charged the full fee on your first session.
* Please note that Mental Health Benefits are different from medical benefits.

After first session, if insurance is verified and diagnosis accepted, then a reimbursement may be made towards some of the first session fee. Co-pay would be expected for the following sessions. Please call our office for more information regarding our insurance policies.  Please fax it to us at 866.776.5116 or e-mail it to us at

Marital Status (please check one)