Inquiry Form

Couples Center of the Pioneer Valley

If inquiring about booking an appointment, please answer the following questions so we can provide you with a list of available appointments based on your insurance, availability, and preferences.
What is your first name? *
Which best describes what you are looking for? *

Individual Therapy Couples Therapy Family Therapy
Contact Information

You will receive an introductory 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 the best number for us to call? *
What is the best email for us to contact? *
example@example.com

Insurance
To find out whether or not we accept your insurance or your partner's insurance, please click here. We do not accept Medicare, Mass Health, or Health New England.

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.

If using insurance, we will 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.
{name}, do you currently have insurance? *

Yes No
Does your partner currently have insurance? *

Yes, they are on the same plan as me. Yes, they have their own insurance plan. No, they do not have 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. *

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 will not be covered by insurance. *

Yes No
When would you be available for appointments?
In a few lines, how can we help you in your current situation?
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Couples Center of the Pioneer Valley