Make a Self-Referral — Family Nest Counseling

Complete the form below to INQUIRE ABOUT therapy.

Unsure if you or your someone you know need therapy? Or unsure which therapy is the best option for you?

Complete the form, and we can find out which therapy, if any is the best option for you or your family.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Therapy Option

It is okay to be unsure what is the best choice.

Health Insurance Carrier

Health Insurance Policy Number

Email Address

Short Description of Reason

Please describe in three sentences or less your reason for requesting therapy. It is okay to be unsure or have multiple reasons.

I have read, understood, and agree to the terms, conditions, and policies below.

Payments Treatment fees will be discussed during your consultation call or in the initial session. Please check with the Behavioral Health Department of your insurance company; their number is typically found on the back of your insurance card, to confirm that we are participating providers of your specific insurance plan. You are ultimately responsible for the fees if not covered by insurance. Payments, co-pays and deductibles are expected at the time of services. We accept cash, check or credit card. Once you are an established client you will be able to make payments online. We can accept payment from some Flexible Spending Accounts, if not we can provide you with an invoice to submit for reimbursement. Cancellation policies We ask that you give a minimum of 24 hour notice when you must cancel an appointment baring emergency and weather related situations. If you cancel within 24 hours, you will be responsible for a cancellation fee of $30.

I HAVE READ, UNDERSTOOD, AND AGREE TO THE TERMS ABOVE