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Couples Counseling

If you are not seeking couples counseling, you can skip this section and submit the form.
Partner's Name

First Name Last Name
Partner's Email
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Partner's Phone Number
Please enter a valid phone number.

Payment Options (Insurance)

If you are not using insurance you can skip to the next section.
Are you planning to use insurance? *

Yes No

At the Austin Mindfulness Center, we have a number of payment options. If you would like to use insurance, the list below indicates all of the insurances that we currently accept. Please be aware that sometimes our therapists who take insurance do not have openings. In that case, you might consider paying out-of-pocket (see below). We can provide you with a superbill to submit to your insurance for out-of-network reimbursement. Please check with your insurance for details about your benefits.

We are currently renegotiating our contract with Blue Cross Blue Shield (BCBS) and are not accepting any new clients using BCBS insurance. For now, you have the option to pay out of pocket to see one of our provisionally licensed associates. We apologize for any inconvenience.
I'm using insurance and my insurance is: *

Aetna Optum / Oscar / United Healthcare/Oxford (EAP program is not accepted)
Insurance Member ID *
Insurance Group # *
Are you the Primary Subscriber listed on this insurance plan? *

Yes No

Primary Subscriber Information

If you are not the Primary Subscriber, please provide additional information about the Primary Subscriber so that we can confirm coverage.
Primary Subscriber Name *

First Name Last Name
Primary Subscriber Date of Birth *

Month Day Year
Date
Relationship to Primary Subscriber *

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