Appointment Request- Nia Noire

I acknowledge that this submission is for the Waitlist only at this time*

Yes, I understand

I acknowledge that Nia Noire is accepting self pay clients only at this time*

Yes, I understand

Name*

First NameLast Name

Preferred Name

Email*

example@example.com

Date of Birth*

Date

Gender - as identified by Insurance*

Self- Identified Gender

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Self Pay/Insurance Details*

Insurance Subscriber ID*

Group ID

Services Interested in:*

How did you hear about our practice?

Psychology TodaySocial MediaWebsiteOther

Please provide your normal availability*

Notes - Please enter any additional information that you would like to provide.

My Products

Nia Noire One-time Admin Fee Product Image

Nia Noire One-time Admin Fee This Virtual Mental Health Practice uses a HIPAA Compliant third party administrative firm to retrieve your inquiry for services. The submission of this form is non refundable and not a guarantee of services. Should we respond to any form submission and we do not receive a response in a timely manner (2 business days) - We reserve the right to suspend a client's service request or cancel the client's submission.This is a one-time, non refundable fee.The payment of this fee guarantees that the Mental Health practice that you are attempting to reach will receive your inquiry, provide a Good Faith Cost Estimate for requested services, and scheduling options in a HIPAA Compliant and timely manner.

$10.00

Total

$0.00

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Appointment Request-Nia Noire