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: *

Blue Cross Blue Shield PPO (Health Select plans or HMO are not accepted) Optum / United Healthcare (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 *

Payment Options (Out-of-Pocket)

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

A discounted rate of $100 with a Therapist Associate (Alison, Ileana, Sable) The standard rate of $120-$125 per session Other

Finding the Right Therapist For You