This *required form is for Prospect/***Returning Clients utilizing Health Insurance or Private Pay to gather basic information such as reason/s for seeking treatment to determine Client-Clinician Match; Preferred Days/Times for Therapy Session/s, and if applicable to gather Health Insurance information so we may promptly provide you with a Benefits Quote / "Good Faith" Estimate and schedule your Intake Appointment.
What Happens Next?
Upon receipt of Appointment Request Form, we will promptly review your submission. **If an appropriate Client-Clinician match, we will subsequently provide you with a Welcome Message containing the following:
Intake Appointment Day/Time
Benefits Quote / "Good Faith" Estimate
Virtual Waiting Room Link (no account set up)
Simply reply "C" to Confirm Intake Appointment.
Yes, scheduling is really that simple!
The Pink Positive Psychology Team
*This is a required form.
**If not a match we will provide referrals.
***Returning clients are previous clients that have not been seen for more than 2-months and or Current Clients with NEW Health Insurance.
Blue Cross Blue Shield - PPO
Blue Care Network
Evernorth Behavioral Health
Out-of-State - Blue Cross Blue Shield Plans
United Behavioral Health
Insurance Opt Out / Self-Pay Rate: $200.00