Insurance Form Is your Insurance Medicaid Based? * Please Note: We do not accept Medicaid Plans. Yes No Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Sex * Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Insurance Provider * Cigna Aetna Empire Blue Cross Blue Shield Oscar Oxford United Health Care UHC Medicare Member ID * Group Number * Are you the primary subscriber? * Yes. I am enrolled individually or through my employer. No. I am enrolled through a parent, spouse, or domestic partner. Subscriber Name First Name Last Name Subscriber Date of Birth MM DD YYYY Interested in * Individual Therapy Couples Therapy If you are interested in Couples Therapy, please provide your partners information below: First Name Last Name Phone (###) ### #### Email If you are interested in Adolescent Therapy, please provide your child's information below: Name First Name Last Name Email Phone (###) ### #### Thank you!
