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Health Insurance Contact Form



All of my counseling sessions are Telehealth Only, no in-person sessions. So you will need access to the internet, your own phone for counselor to get in touch with you in case of technical difficulties, and your own email address where you can receive appointment reminders and document requests. * 

Email Address*

Do you have an active Medicare policy?* (Counselor is not currently a Medicare Provider.  If you are still interested in Self-Paying for counseling services please use the Self-Pay form to receive the current Self-Pay rates) 

Do you have an active Medicaid policy?* (I do not accept NC Medicaid) 

Have you been court ordered for counseling services or was it recommended by your lawyer, Child Protective Services, or the Department of Social Services? *

Do you have current or pending legal issues? *

Have you had any recent Hospitalizations (due to mental health or substance abuse issues), In-Patient Counseling Services, or time served in jail/prison? *

Is there any certain day or time you would need services due to other obligations?* (Current appointment hours are Monday-Thursday 11:00 am-5:00 pm. I am closed Friday, Saturday, and Sunday) 

How often were you planning to attending counseling services?*

What issues/problems were you wanting to address in counseling services? *

Full Name on Your Insurance Card *

Your Date of Birth*

Street Address*



Zip Code*

Name of Insurance Provider*

Member ID Number *

Phone Number to Provider Services (or Behavioral Health) *

Name of Primary Insurance Holder (if this is someone other than yourself)

Primary Insurance Holder Date of Birth

Primary Insurance Holder Home Address

By checking Yes I acknowledge and understand that not all issues/problems are appropriate for Telehealth mental health counseling services. If at any time my counselor feels I would benefit more from In-Person Counseling Sessions then I will be given referrals to other providers in the area. I understand that during the Initial Counseling Session the counselor and I will discuss my counseling goals/objectives and determine if Telehealth Counseling is appropriate for me and if the counselor is a good fit for my needs. *

Message- If you have a secondary insurance policy please list the name of the policy here. Thanks! 

Your form has been submitted! Please allow 3-5 business days for a response. Thanks!

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