To avoid disruption of treatment due to insurance changes in the new year, please provide the requested information in this form. 

Thank you, we look forward to assisting you.

Type your therapist's first and last name.
Patient's Name *
Patient's Name
If client is a minor, please complete the parent/caregiver field as well.
Name of Parent/Caregiver (If Applicable)
Name of Parent/Caregiver (If Applicable)
Required Insurance Information
This prevents issues with insurance disrupting treatment in the new year, please complete the following information.
For BCBS, please include the three letter alpha-prefix. For Tricare, we need the policy-holder's SSN or DOD number.
We will do our best to respond to all questions and comments as soon as possible.