Insurance Reimbursment Inquiry

Please complete the form below to verify your insurance benefits and determine your potential reimbursement eligibility.

This form is securely linked to a HIPAA-compliant patient portal to protect your privacy and confidentiality.

First name*

Last name*

Phone Number

Email*

Date of birth*

Month

Day

Year

Insurance Provider*

Member ID*

Group Number (if applicable)

Name of Policy Holder (if different)

Relationship to Policy Holder*

Self

Spouse/Partner

Parent

Other

What services are you inquiring about? (Check all that apply)*

Individual Therapy

Family Therapy

ADHD Coaching

Case Management

Other

Any specific questions or concerns about insurance reimbursement?

I declare that the info I’ve provided is accurate and complete.

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