Self-Pay / Out-of-network Inquiry Form

If you prefer paying for your mental health services out-of-pocket, or use your insurance plan’s out-of-network benefits, please submit your inquiry using the form below. If you are going to apply for out-of-network reimbursements from your insurance provider, we are not able to submit out-of-network claims on your behalf but we can provide you monthly superbills for you to submit to your insurance company and we recommend you to use services such as Reimbursify.com or Getbetter.co.

If you prefer using your in-network insurance benefits, please submit our Insurance Verification Form instead.

If you would like to learn more about our practice’s policies, please visit our Frequently Asked Questions (FAQ) page.

Personal Information

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Goals and Preferences



Miscellaneous

(e.g., motional support animal letter, FMLA paperwork, short term disability paperwork, court documents)


Identification Documents

Click or drag files to this area to upload. You can upload up to 2 files.
e.g., Driver's License, State ID card, Passport Card, Passport first page, or similar.

Acknowledgements



   
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