Inquiry Form

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 ONLY accept and can bill in network for:
*all Blue Cross/Blue Shield plans and
*all United Healthcare products including UBH, Harvard Pilgrim, and Optum.

We can usually bill one person’s health insurance ( “identified patient “) for a family therapy session.
The remainder of the cost of the session will need to be paid out of pocket.

If you are using one of these accepted in-network insurances we ask that you provide insurance information on this form so that we can run your benefits and let you know what they will cover and any deductible or copay you are responsible for.

If you have out of network benefits, you will need to pay out of pocket; the identified patient may absolutely request a superbill from your clinician to seek reimbursement from your insurance company and we will be happy to provide that.

Darrel Jones
Senior Intake Coordinator
Northampton, MA 01060
COVID-19 Update: Our building is closed and we are now operating virtually.
www.pioneervalleycouplestherapy.com
(413) 570-0067
{name}, will you be using your insurance? *

Yes No
Will your partner be using their insurance? *

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. *
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. *

Specialized Services

If using insurance, the wait time for an appointment may be 6-8 weeks. In cases where the conflict is urgent or time-sensitive, we offer a limited number of openings for people looking to begin couples therapy sooner. Please note that our specialized services below are not covered by insurance.
Would you be open to a consultation call from a licensed therapist to learn more about our specialized services? This includes discernment counseling, rapid access appointments, and mini-intensives which are not covered by insurance. *

Yes No
Which of the following would you like to learn more about? *

Discernment Counseling Rapid Access Appointment Mini-Intensive
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