Traverse Therapy Services

Traverse Therapy Services

Please complete this form, in order to schedule an appointment. You will receive an invitation to our secure client portal, scheduling and cost estimate details.
Client Type*

AdultFamily/CoupleMinor
Client Name (Minor)*

First NameLast Name
Preferred Name (Minor)*
Client (Minor) Date of Birth*

MonthDayYear
Date
Client Name (Responsible for Billing)*

First NameLast Name
Preferred Name*
Client Date of Birth*

MonthDayYear
Date
Client Email (Responsible for Billing)*
example@example.com
Phone Number*
By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging.
Client Name 2*

First NameLast Name
Client 2 Preferred Name*
Client 2 Date of Birth*

MonthDayYear
Date
Client 2 Email*
example@example.com
Phone Number*
By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging.
Gender - as identified by Insurance*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance or Self Pay*
Would you like to apply for the sliding scale discount? (Proof of income required)

YesNo
What is the size of your household?
Number of people
What is your household income?
Annual income
Proof of income ( Last 2 paystubs or fixed income statement)

Cancelof
Insurance Subscriber/Guarantor Name*

First NameLast Name
Insurance Subscriber/Guarantor Date of Birth*

MonthDayYear
Date
Insurance Payer Name (ex. BCBS)*
Enter 0 if Self Pay
Employer ( Insurance Plan )
Company Name
Insurance ID # *
Upload a Copy of your insurance card (front)*

front
Cancelof
Upload a Copy of your insurance card (back)*

back
Cancelof
Upload a Copy of your insurance referral (if available)

front
Cancelof
Notes - Please enter any additional information that you would like to provide.
Interested In:*

In- PersonTelehealth/ Virtual
Interested In:*

Individual TherapyCouples / Family Therapy
Availability Day*

MondayTuesdayWednesdayThursdayFridaySaturday
Availability Time*

MorningEarly AfternoonLate Afternoon
Have you already been contacted about scheduling?*

YesNo
Name the person were you in contact with*
Who scheduled your appointment?
How did you find us?*

Psychology TodayWebsitePhone Call

My Products*

Traverse One-time Admin Fee Product Image

Traverse One-time Admin FeeThis Virtual Mental Health Practice uses a HIPAA Compliant third party administrative firm to retrieve your inquiry for services. We use this administrative form and fee to verify identity and payment details on behalf of our therapy practice. The submission of this form is non refundable and not a guarantee of services. This is a one-time, non refundable fee. The payment of this fee guarantees that the Mental Health practice that you are attempting to reach will receive your inquiry, provide a cost estimate for requested services, and scheduling options in a HIPAA Compliant and timely manner.

$2.00

Total

$0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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