PRO TIP:  Take Pictures of Drivers License/ID (front & back) & Health Insurance Card/s (front & back) BEFORE filling out this form. 

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Appointment Request & Insurance Verification Form

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For all *Prospect Clients and Returning Clients, this 5-7 minute form assists us in understanding your treatment needs, ensuring an optimal client-clinician match. It also captures your scheduling preferences. Kindly complete and submit this form, and we'll swiftly provide you with a **Benefits Quote** and arrange your Intake Session based on your preferences. 

 

What's the Next Step? 

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You'll receive a Welcome Message with:

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• Your Intake Appointment Details 

• Benefits Quote or "Good Faith" Estimate

• Intake Forms 

• Link to Virtual Waiting Room

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To confirm the Intake Appointment, simply reply with "C".  

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It's that easy to schedule with me!

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Warm Regards, 

Melissa E. Mendoza, LMSW

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🔗LinkTree Link:  https://linktr.ee/pinkpsy

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*If not a match we will provide referrals.

**No obligation or cancellation fees if you decide not to proceed with the session based on the provided benefits quote.

***All Forms are Mobile Friendly / Electronic Forms that are HIPPA compliant and ENCRYPTED which means your information is safe and secure.

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