Inquiry Form

Couples Center of the Pioneer Valley

Please answer the following questions so we can provide you with a list of available appointments based on your insurance, availability, and preferences. If you are a current client, you may also use this form to update your insurance information.
Please select the option that describes you best. *

I am wondering if you have openings available for appointments. I am a current client and I would like to update my insurance on file.
Which best describes what you are looking for? *

Individual Therapy Couples Therapy Family Therapy
Contact

You will receive an email with information on what to expect from our center upon the form submission. We will follow up with a response within 1-2 business days.
What is your first name? *
What is the best number for us to call? *
What is the best email for us to contact? *
example@example.com

Services

We offer appointments 7 days a week in the mornings, afternoons, and evenings. The more flexibility there is in your schedule, the more appointments we are able to offer.
Are you in a crisis? *

Yes No
Are you at the brink of separation or divorce? *

Yes No
We have recently opened a select number of time slots reserved for urgent or time-sensitive conflicts. Would you be open to a consultation call from a licensed therapist to learn more about our specialized services? (Please note that our specialized services are not covered by insurance. If using insurance, the wait time for an appointment is 2-4 weeks). *

Yes No
When would you be available for appointments?
In a few lines, how can we help you in your current situation?

Insurance

If using insurance, we ask you to provide your insurance information on this form so that we can run your benefits and notify you how much your insurance is going to cover and if there is any deductible that needs to be met.
We accept all Blue Cross/Blue Shield plans and all United Healthcare products (UBH, Harvard Pilgrim, Optum, etc.). We also accept Allways, UMR, Oxford, Health Plans Inc., and some (but not all) Tufts plans.

Most GIC plans have out-of-network benefits as well as Unicare, Cigna, Consolidated Health Plans/Wellfleet, Aetna, and any other insurances that have out-of-network benefits.

We do not accept Mass Health, any Health Connector or Commonwealth Care plans, Health New England, Medicare, Tricare, and Beacon. If one partner has an insurance plan that we take and the other partner does not, the sessions will be partially covered and we can estimate what the cost of the sessions will be.

For couples therapy, we require that both partners provide their insurance information. Sessions are billed as two 38 minute sessions, one to each partner’s insurance plan. So, the cost of the session will be your two copays or your percentage of what your insurance plan isn’t covering.
{name}, would you like us to check your insurance coverage? *

Yes No
Would your partner like to check their insurance coverage? *

Yes, they are on the same plan as me. Yes, they will be using a separate insurance plan. No, they will not be using insurance.
If both of you are on the same plan, please provide your insurance information below. *
{name}, please provide your current insurance information below. *
Please provide your partner's current insurance information below. *
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform