Emergency Contact Info:
Height blanksWeight poundsAre you currently taking any medications? Yes No Are you currently in counseling or therapy? Yes No Have you ever been admitted to inpatient for mental health or substance abuse? If so when and where: Date Date Date
We are in network with BCBS and UHC; please make sure you have included your insurance informationa and that we have verified coverage. You may have a copay, coinsurance, or allowable due based on your coverage and this is due at time of service (or before).
Self pay rates are $300 for initial consultation and follow ups are $150. Payments can be submitted via the payment portal on our website or by calling the office. Please provide 24 hour notice for all cancellations and reschedules. We understand things do come up, but please email, text, or call the office as soon as possible so that we can offer your time to someone else. There is a $50 no show/late cancel fee.
I hereby consent to evaluation, testing, and treatment as directed by my Aware Behavioral health physician or his or her designee.