Therapy Client Inquiry Form

Parent/Guardian Name and Information

If you are submitting this inquiry for your child, we'll need a little more information about you.
What is your name?*

First NameLast Name
What are your preferred pronouns?
Optional
What is your child's date of birth? [ARCHIVED QUESTION]

MonthDayYear
Date
What email address should we use to contact you? If you already entered your email address on the previous page, you can leave this field blank.
example@example.com
What phone number should we use to contact you? If you already entered your phone number on the previous page, you can leave this field blank.
If different from the Client's home address, what is your home address?

Street Address

Street Address Line 2

CityState

Zip Code

Therapy Accessibility and Finances
BaMidbar Therapy promotes self-reflection and therapeutic growth, while helping participants build a toolkit to face life’s challenges. We recognize that one of those challenges is accessing affordable therapy services. BaMidbar Therapy is working hard to get contracted with a variety of insurance agencies.

Click here to view therapy FAQs, including an up-to-date list of accepted insurance companies:
- Blue Cross Blue Shield (MA clients only)
- Tufts Health Plan (MA clients only)
- Optum/United Healthcare (MA clients only)
- Cigna (MA clients only)
- Aetna (MA clients only)
- Harvard Pilgram Healthcare (MA clients only)
Depending on your insurance coverage, you have a few options:
1. If you are covered by one of these insurance companies, you will enter that information.
2. If you are not covered by one of these insurance companies, you will have the opportunity to answer a few questions to apply for a sliding scale fee reduction.
3. If you'd prefer to submit claims for out-of-network benefits, please notify your provider during your first session.
Are you covered by one of BaMidbar's accepted insurance companies?*

Blue Cross Blue ShieldTufts Health PlanUnited HealthcareCignaAetnaHarvard Pilgrim Health CareI am NOT covered by one of BaMidbar's accepted insurance companies.
What is your insurance? BaMidbar gathers this information to make informed decisions about adding insurance companies to our accepted list. *
Are you covered by one of BaMidbar's accepted insurance companies? [ARCHIVED QUESTION]

I AM covered by one of BaMidbar's accepted insurance companies.I AM NOT covered by one of BaMidbar's accepted insurance companies.

Finances | Insurance
Insurance Subscriber Name*

First NameLast Name
Insurance Subscriber Member Number*
Insurance Group Number
Insurance Card Photo (FRONT): Please upload a clear image of the front of your insurance card*

Cancelof
Insurance Card Photo (BACK): Please upload a clear image of the back of your insurance card*

Cancelof

Finances | BaMidbar's Sliding Scale
If you are not covered by one of BaMidbar's accepted insurance companies, BaMidbar offers a sliding scale to establish session fees.

Would you like to submit your financial information to receive a reduced rate based on BaMidbar’s sliding scale? If you choose not to provide this information now, you can provide it at any point in the future to receive a reduced rate. More information about our fee structure can be found here.

Upon notice of a fee change, your fee is valid for up to six months or until BaMidbar accepts your insurance. If BaMidbar does not accept your insurance after six (6) months, or should your financial situation change over the next six (6) months, we may ask for you to resubmit this form.
Select this box to answer a few questions to apply for a sliding scale fee reduction.

I'd like to answer a few sliding scale fee reduction questions
How many people are in your household?*
Who should be included in your household? For this form, a household usually includes a tax filer, their spouse if they have one, and their tax dependents. If you are counted as a dependent on someone else’s tax returns, you should include their annual adjusted gross income and household size.
Household annual Adjusted Gross Income (AGI):*
As reflected on your latest tax return.
Do you have any additional financial responsibilities that impact your ability to pay for therapy? (student loans, medical debts, family caregiving, etc.)*

Yes, I have additional financial responsibilities.No, I do not have additional financial responsibilities.
Describe your additional financial responsibilities:*
Do you receive financial support from outside sources such as parents, caregivers, family members, etc.? (Financial support can include, but is not limited to, support with rent, food, tuition, utilities, car payments, or health insurance).*

Yes, I receive financial support.No, I do not receive financial support.
Contribution dollar amount:*
Frequency of distribution:*
Describe the type of support:*

How should we contact you?
By checking the box below I acknowledge:*

Email Me: Conventional email is inherently insecure and therefore poses a risk to the privacy and security of my Protected Health Information. I accept these risks and consent to BaMidbar’s therapists and office staff communicating with me via unsecured email with regards to scheduling, billing, and payment for healthcare services. I am not required to give this consent in order to receive treatment.Call Me: I only wish to be contacted via secure communication means, or at the phone number provided, until such time as I may elect to make a request for communication via non-secure means.
Can we leave a voicemail at the phone number provided?

Yes, you can leave a voicemail at the number provided.
Please verify that you are human*
Should be Empty:

Therapy Client Inquiry Form

Parent/Guardian Name and Information

We'd like to ask you a few questions about what you're seeking in therapy.

Therapy Accessibility and Finances

Finances | Insurance

Finances | BaMidbar's Sliding Scale

How should we contact you?