Getting Started With Momwell

In order to get started with care at Momwell, there are a few questions we need to ask to help us understand where you're located, how you’d like to access care, and whether we currently offer services in your area.

It should only take a couple of minutes to complete. Once submitted, our team will review your information and follow up with your next steps.

Please note that the services we’re able to offer may vary depending on your province or state.

How would you like to get started?*

Name*

First NameLast Name

Email*

example@example.com

What country are you located in?*

What state are you located in?*

What province are you located in?*

Service Type

Region Status

Are you looking for therapy or an assessment?*

In Network Status

Assessment Region Status

Are you looking for individual or couples therapy? *

Are you looking to book directly with Erica?*

*Please note that Erica's rate is $200 CAD per session

Are you looking for in network services or cash pay?*

Unified Region

Your Phone Number*

Format: (000) 000-0000.

Your Birth Date*

Date

Would you like to sign up for direct billing with your insurance provider (if eligible)?*

What Insurance provider are you with?*

Please note: If you don't see your insurance company here, that means we cannot support direct billing at this time. Please select no in previous drop down.

Your relationship to the insured member?*

Partner's Name*

First NameLast Name

Partner's Email*

example@example.com

Partner's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Partner's Birth Date*

Date

Thanks so much for your interest in Momwell. While we're not currently offering ADHD Assessment services in your state, we're always exploring opportunities to expand where and how we support moms. If you'd like to be notified when services become available in your area — you can join our waitlist by clicking submit below.

Thanks for your interest in Momwell's ADHD Assessment. We're not yet offering assessments in Canada, but we'd love to keep you posted. Leave your details and we'll reach out as soon as assessments are available in your area.

Thanks so much for your interest in Momwell.

While we’re not currently offering services in your area, we’re always exploring opportunities to expand where and how we support moms.

If you'd like to be notified when services become available in your province, you can join our waitlist below.

Thanks so much for your interest in Momwell.

While we’re not currently offering services in your state, we’re always exploring opportunities to expand where and how we support moms.

If you'd like to be notified when services become available in your area—or if we become in-network with your specific insurance provider—you can join our waitlist below.

Just let us know who your insurance company is so we can keep your information on file and reach out when we’re able to support you.

Great news! We currently offer assessment services in your state!

Next we will ask a series of basic ADHD screening questions and a few other basic pre-screening questions to ensure you are a suitable candidate for a virtual assessment. Once our team has reviewed your responses we will follow up via email to share the status of moving forward with your assessment and next steps for getting started.

We currently offer therapy services in your state, we just need to collect a few final details so our team can follow up with you by email.

From there, we’ll walk you through what to expect, share session details and pricing, and help get you paired with one of our therapists.

Which insurance provider are you with? CA*

Which insurance provider are you with? TX*

Which insurance provider are you with? PA*

Which insurance provider are you with? IL*

Which insurance provider are you with? FL*

Which insurance provider are you with? NY*

Which insurance provider are you with? VA*

Thanks so much for reaching out—we’re so glad you found us.

While we’re not currently in-network with your insurance provider, services are available in your state through our cash-pay option.

If you’d prefer to wait for insurance coverage, you’re welcome to join our waitlist and we’ll reach out if and when that changes.

For either the waitlist or to continue cash-pay there are some additional details we need to collect.

Would you like to get started now with cash-pay, or join the waitlist?*

What insurance company are you with?*

Please specify your insurance provider

Partners Healthie Group

Healthie Tags

Insurance Unified

Member/Certificate # (found on insurance card)*

Healthie Group

Group/Policy ID # (found on insurance card)*

Please upload a picture of the front and back of your membership card*

Annual coverage and/or max per session amount for mental health services?*

Estimated annual coverage remaining?*

Registered Social WorkerRegistered PsychologistRegistered PsychotherapistRegistered Clinical Counsellor

Do you have additional coverage/insurance? *

What brings you to Momwell right now? (This helps our team understand your needs and pair you with the best-fit therapist.)*

MorningAfternoonEvening (If available)

You’re almost done!

Once you click submit, our team will follow up within 24–48 hours with your next steps. We’ll walk you through onboarding, help pair you with a therapist, and answer any questions you may have.

Session rates in Canada typically range from $150–$220 CAD, depending on your therapist. Please be sure to hit Submit below so we can begin your care.

Once you click submit, you're all set!

We'll now review your insurance details and verify your coverage with your provider. This allows us to confirm your benefits, including whether any copay or deductible applies, so you know exactly what to expect.

Once we’ve completed the check, we’ll follow up by email with a summary of your coverage and a few quick steps to get your secure client portal and billing account set up.

After that, we’ll be ready to pair you with one of our therapists and schedule your first session. Be sure to click Submit below so we can begin your care.

We're excited to support you― you're almost done!

After you submit, our team will follow up by email within 24–48 hours to guide you through onboarding and therapist matching.

Session rates typically range from $175–$220 USD, depending on your therapist.

We're excited to support you― you're almost done!

After you submit, our team will follow up by email within 24–48 hours to guide you through onboarding and therapist matching.

Couples therapy at Momwell is offered cash pay only and is not a part of our in-network service offering.

Session rates typically range from $175–$220 USD, depending on your therapist.

***ATTENTION: Please note that when your booking is confirmed here in Calendly, you still need to click "SUBMIT" on this form submission below

You're Almost Done!

Don't forget to click SUBMIT below to complete your form!

Once you submit, our Care Coordinator will call you at your scheduled time and guide you through the onboarding process answering any questions that you might have during your call.

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Have you previously submitted the Momwell ADHD Screener Quiz form?

Do you:

Rows	Yes	No
1. Often make decisions impulsively
2. Often have difficulty stopping activities or behavior when you should do so?
3. Often start projects or tasks without regarding or listening to directions carefully?
4. Often have poor follow-through through on promises?
5. Often have trouble doing things in proper order?
6. Often drive with excessive speed?
7. Often become distracted by extraneous stimuli?
8. Often have difficulty sustaining attention in tasks or leisure activities?
9. Often have difficulty organizing tasks and activities?

Is your life impaired/affected in your:

Rows	Yes	No
1. Occupation or Job
2. Educational Activities
3. Social Life

When you were a child did you?

Rows	Yes	No
1. Often fall to give close attention to details or make careless mistakes in your work?
2. Often have difficulty sustaining attention in tasks or fun activities?
3. Often feel restless?
4. Often avoid, dislike, or were reluctant to engage in work that required sustained mental effort?
5. Often forget things in your daily activities?
6. Often interrupts or intrude on others?

YesNoNot Applicable

If you have children, what are their ages?

YesNo

Please list the diagnosis(es) and the medical provider who provided the diagnosis(es) (ie. Primary Care Provider, Nurse Practitioner, Psychiatrist, Self-Diagnosed)

YesNo

If you answered yes above, please provide more detail.

YesNo

Cash PayInsurance

YesNo

Momwell's Comprehensive ADHD Assessment is an out-of-network service and is paid for out of pocket. However, we have partnered with an out-of-network insurance partner that can assist with out-of-network reimbursement from your insurance provider. Since we don't already have your insurance information on file, we are collecting it in order to provide an estimate of out-of-network reimbursement from your provider and will provide you with this estimate during the onboarding process. Once the assessment and report are complete we will also assist you with submitting your superbill to your provider to recoup the reimbursement amount. Please add your insurance information below.

What insurance company are you with?*

Member/Certificate # (found on insurance card)*

Group/Policy ID # (found on insurance card)*

Please upload a picture of the front and back of your insurance card*

How did you hear about Momwell?*

If other please elaborate

If Doctor or Healthcare Provider please list the name or facility that referred you.*

Once you click submit, you're all set!

We'll now review your screening responses within 24-28hours and confirm if you are appropriate to proceed with the assessment. We will also verify your out-of-network coverage with our partners in order to share this estimate information with you. We'll follow up by email with the assessment cost appraisal details, an estimate of your out-of-network reimbursement amount and the next steps to begin the process.

Be sure to click Submit below so we can begin your assessment review.

I understand that Momwell is not a crisis service and I confirm that I am not in crisis.

I agree to receiving text messages for support in the intake process

By providing a telephone number and submitting the form, you are consenting to be contacted by SMS text message and agreeing to our Privacy Policy. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information.

Get Started With Momwell

ADHD Screening Questions