Request an Appointment

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 *
example@example.com
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.
I'm using insurance and my insurance is: *

Aetna BCBS PPO Optum / Oscar / United Healthcare/Oxford (EAP program is not accepted)
Insurance Member ID *
Insurance Group # *
Legal Sex (If using insurance, select the sex on file with your insurance policy. Insurance companies require this information for billing) *

Male Female Undefined
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 *

Payment Options (Out-of-Pocket)

If you are using insurance you can skip to the next section.
I can afford: *

The standard rate of $130 -$150 per session A discounted rate of $100-$120 with a Therapist Associate (LMSW, LPC-A) I am interested in $50 half-price therapy with LPC Associate Jennifer Nuño (Telehealth Only)

Good Faith Estimate

One final formality and then we're done!
The Good Faith Estimate is a mandate implemented January 1, 2022 by the Federal Government. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services to prevent "surprise" medical billing and has been applied to all medical providers and facilities. It "forces" medical providers to list fees clearly to clients.

Austin Mindfulness Center has always provided transparency in our billing practices by displaying our fees on the website.

Your review of this form and signature is required so that we can demonstrate our compliance with the mandate. Thank you!
Good Faith Estimate with option to view and download.
Good Faith Estimate Signature: By signing here, you are confirming that you have been provided a copy of the Good Faith Estimate, as mandated by the No Surprises Act.

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Finding the Right Therapist For You