1. Demographic and Insurance Information

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* 1. Identifying Information

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* 6. Responsible Party (if different than client)

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* 7. Insurance Information. Please read carefully.

As of January, 2023, I am not accepting the "in-network" contractual reimbursement rate I have with MEDICARE, BLUE CROSS, AETNA and CIGNA insurances. This means that if you choose to go forward using one of these insurances your copay will be higher than if you utilized another "in-network" provider.  I am still willing to bill your insurance and accept their reimbursement rate as part payment but your copay will be the difference between the actual reimbursement rate and my standard fee which is $195 per session. If this is unacceptable to you (which I completely understand), I am sorry I am not in a position to accept your insurance and so it might serve you to seek another in-network provider.

If this is acceptable, please complete your insurance information below or text me a copy of your insurance cards front and back (949-295-9203) in lieu of completing the information below.

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