Charlottesville Marriage New Client Contact Form

If you are interested in becoming a new client, please complete the information requested below (this is a secure form and all of your information will be kept confidential). Within 48 hours of submitting the below information, Dr. Young will send you an email confirmation (please check your spam folder if you do not see an email from us within a week).

Dr. Young is offering teletherapy (video) sessions as well as in-person sessions. He is not in-network with any insurance provider. His fee is $175 per session. We recommend checking with your plan to see if you have out of network benefits that might cover some or all of his fee. If so, we are happy to file those claims for you. We will collect the full fee up front, and if your insurer pays toward your sessions, they will likely send you payment directly. He is a certified non-network provider with Tricare East.

Client Name

Date of Birth

Email address

Phone Number

Will your partner be attending sessions with you? (We will send intake paperwork to your partner if they will be attending sessions with you)

Yes, my partner will be attending at least some of the sessions with me. No, I will be attending sessions alone.

Partner's Name

Partner's Date of Birth

Partner's Email Address

Do you have insurance? If so, who is your provider?

Dr. Young is not in-network with any insurance providers. We recommend checking with your plan to see if you have out-of-network benefits that might cover some or all of his fee. If so, we are happy to file those claims for you. We will collect the full fee up front, and if your insurer pays toward your sessions, they will likely send you payment directly. He is a certified non-network provider with Tricare East.

Do you need a particular day or time for an appointment? Or do you prefer to be notified of the first available time?

Do you prefer to be seen via teletherapy or in person?

Use this space to give us a little more information about why you are coming in or what you are looking for from therapy. Please note that this information will be viewed by our office manager.

Your information will be encrypted.

Charlottesville Marriage New Client Contact Form

Rob Young, PsyD