Questionnaire

 

*This is not the initial intake form, please fill this questionnaire out for initial interest only.

Please complete the questionnaire form below to help our front office staff provide you with a referral that will best suit your needs.

Name *
Name
Phone *
Phone
How were you referred to our center?
Which office location would be most convenient for you?
Which of the following are you interested in seeing?
Would you like us to bill your health insurance?
We are able to bill any PPO insurances as an out-of-network provider. If you have Blue Cross Blue Shield PPO insurance, Blue Cross Blue Shield will only recognize claims from Licensed Master-level or Doctoral-level Therapists. We are in-network providers for Medicare Part B, Tricare, and TriWest (VA) ONLY. If you have an insurance plan with out-of-network benefits, we can bill your insurance as a courtesy to you. To verify if you have coverage for our services, call the customer service number on your insurance card. Be sure to bring any insurance information with you when you come in for your first appointment.
Is there a specific specialty you are looking for?
What is your gross monthly household income?
Please fill this portion out only if you wish to see a Registered Associate and would like to see if you qualify for a fee reduction due to financial limitations.
How many are in your family?
Please fill this portion out only if you wish to see a Registered Associate and would like to see if you qualify for a fee reduction due to financial limitations.