New Client Appointment Request

Please note:

Services are available for individual adults. This practice is not currently serving couples, families, or anyone under age 18.

Date, time and therapist will be determined by availability & insurance match

First Name

Last Name

Email Address

Phone Number

Date of Birth

Are you interested in being seen in the office or remotely?

In-person Video

How were you referred to us?

Do you plan to use insurance? Please note this practice does not participate with any Medicaid or Medicare plans.

Yes

For either In-Network or Out-of-Network insurance benefits.

Private pay

Insurance Company Please note these options do not include any Medicaid or Medicare plans managed by these or other companies. Please contact the practice with any insurance questions.

Independent Health

Includes Nova

Highmark Blue Cross Blue Shield (BCBS)

Includes BCBS FEP & Anthem BCBS

Aetna

Includes Meritain

Univera Out-Of-Network

Insurance card images Font & Back

Add file

Please upload a file

Acknowledgment

DOB, address, and phone number of primary insured will be needed to process claims for spouses or dependents of primary member.

Acknowledgment

The insurance selected is not a Medicaid Managed Care Plan or a Medicare Advantage plan and I am not a Medicare recipient.

When are you available for your first session?

More time slots will help us schedule your initial session sooner.

Add Another Day

Question

This will help validate the form submission

Question?

Additional information:

Permission to contact you

By checking this box I agree to be contacted by J. Higgins Counseling, LCSW, P.C. via phone, voicemail, text or email.

Your information will be encrypted.