Appointment Request

1
Your Basic Information* This field is required.
First Name
Last Name
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DC
FL
IN
MD
MA
VA
State of Residence
2
Can you tell me a bit about what is bringing you to see me?
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3
Do you Have Insurance?* This field is required.
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4
Insurance Information
Aetna (Commercial and Federal)
Aetna Better Health of VA
Anthem/BCBS (Commercial and Federal)
Anthem Healthkeepers Plus
Anthem Hoosier Healthwise
Beacon Health Options
CareFirst BCBS (Commercial)
CareFirst Community Health Plan
Cigna
Coventry Healthcare
Magellan/Molina Healthcare (Commercial and EAP)
Magellan/Molina Complete Care of VA
Meritan Health
Optima (Commercial)
Optima Family Care
Tricare
United Healthcare
INSURANCE COMPANY
INSURANCE ID NUMBER
INSURANCE GROUP NUMBER
YOUR DATE OF BIRTH
POLICY OWNER/SPONSOR
5
Please upload a front and back copy of your cardA picture with your phone is fine
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Max. file size: 10.6MB
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6
How much money do you bring home each month?An Estimate is okay
7
Does this look right for your income per year?If not, please click on "previous" and change the number
8
In an effort to reduce the cost associated with individuals that sign up for treatment and then do not show up for the first appointment, we are now requiring the no show fee to be collected in advance as a deposit. This will be billed to you once we confirm your appointment and put you in our system.

This $55.00 charge can be credited to your account or refunded to you upon presenting for your appointment. If you do not show up for your intake appointment, no refund or credit will be issued.

Please click next if you agree to these terms. If you have any questions, please let us know.
9
When would you like to come in?
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Do you have any questions for me?
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