Zillennial Intimacy | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Are you part of a couple or in a relationship?

Age of client(s)

Billing & Payment

How do you plan to pay?

The full rate for sessions is $250/hour, but understand this is not always possible for everyone. If you are unable to afford full-fee therapy, you can check to see the suggested rate for your income bracket for sliding scale spots. If availability allows it, sliding scale clients will be accepted or placed on a waitlist.

For sliding scale rates: What is your combined household income?

This helps determine your eligibility for a lower rate (sliding scale) session.

Superbill Insurance Reimbursement Acknowledgment

I understand that to receive a superbill, sessions must be billed at or near the clinician’s standard rate. I understand that a diagnosis is required for insurance reimbursement. I understand that reimbursement is determined by my insurance plan, and that the therapist is not responsible for claim approval, reimbursement amounts, or payment timelines.

I understand

Insurance Information (for out-of-network benefits)

I have a PPO plan with coinsurance OON benefits (eligible for superbills) I have a HMO plan (not usually eligible for coinsurance) I know my deductible amount for the year I am close or have hit my deductible for the year I don't have insurance and need a sliding scale rate I want privacy and don't wish to get insurance involved

Client Preferences

Is there anything that you would like to share?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.