Insurance Verification

You’re one step closer! We accept your insurance. Now we just need to verify coverage. Please fill out the form below.

Date

MM

DD

YYYY

Personal Information

Name

First Name

Last Name

Middle initial

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Date of birth

MM

DD

YYYY

Last 4 digits of SSN#

Insurance Information

Name of Employer

Insurance Provider

Member ID

Group Number

Effective Date

MM

DD

YYYY

Insurance Company Customer Service Telephone Number

(###)

###

####

What is the reason for seeking counseling/therapy services?

“We turned our can’ts into cans, and our dreams into plans. Are you ready to do the same?”