Appointment Request

Request an Appointment

Complete this quick form to check your insurance benefits and we'll reach out to schedule.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Contact Method*

PhoneEmail

Insurance Carrier*
Don’t have any of these health plans? You may still be able to use your benefits! Some plans reimburse a portion of “out-of-network” providers. Contact your plan and inquire about “out-of-network” mental health coverage. Aloha Psych can provide “Superbills” that you may be able to submit to your plan for reimbursement. In this case, you will pay the full rate up front
Primary Member Name (or TRICARE Sponsor Name)*

First NameLast Name
Member ID Number (or Military Sponsor Social Security Number)*
Provider Service Number
Located on back of card
Insurance Card - Front*

Please upload a copy of the FRONT of your insurance card
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Insurance Card - Back*

Please upload a copy of the BACK of your insurance card
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TRICARE: Uploading a copy of your Military ID is required per DoD.

How Did You Hear About Us?*
Name of Referral
Provider or Organization
What's That Something Else?
Anything We Should Know?
Disclaimer:

By completing this form, you are authorizing us to verify your insurance benefits and contact you directly, including future marketing outreach. Please note that correspondence with our organization does not in and of itself suggest or imply a professional relationship of any kind. Unless a patient has been accepted into our practice and a professional relationship has been formally established, correspondence here is not confidential nor covered under applicable laws related to the practice of psychology or medicine in California or relevant ethics codes, with a few exceptions. At any time, should it be disclosed that a child has been abused, an elderly person has been abused, or an individual is about to take action that could cause serious bodily harm to another individual or to property that could cause harm to another individual, confidentially does not apply and a licensed psychologist, licensed marriage family therapist, licensed social worker or physician in the state of California is mandated by law to report such an incident, regardless of which state the incident has occurred, and regardless of whether the person has previously established a professional relationship with him or her.
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Request an Appointment