Benefits

Fill out this private and confidential form to see the services your insurance may qualify you for.

 
 

 
 
Name *
Name
Phone *
Phone
Select your current insurance carrier
Please write in the member ID on your insurance card
(MM/DD/YYYY)
Please list Street Number & Name, City/State/Zip
Please list a brief summary of any antidepressant or other psychiatric medication trials.

By hitting submit, you are agreeing to our Benefits & HIPAA policy

 
 

 

We Contract with All Major Carriers:

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