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Services
Which services are you interested in? (check all that apply)

Other
What format are you interested in?

Other
Couples Therapy
Couples therapy may be covered by some insurance plans when treatment is focused on a diagnosable mental health condition affecting one member of the relationship. However, many relationship concerns, communication challenges, premarital counseling, and relationship enrichment services are not covered by insurance. If you are seeking support primarily for your relationship, private-pay options and Therapy Intensives may be available. Our team can help you understand your options during the consultation process.
Family Therapy
Family therapy services are often covered by health insurance when medically necessary and focused on a diagnosable mental health concern. Coverage varies by plan, and some family-based services may have limitations.

Our team will verify benefits prior to scheduling whenever possible and discuss any anticipated out-of-pocket costs with you.
Youth Inquiries

For clients under 18, a parent or legal guardian must participate in the intake process and complete all required consent documentation prior to services beginning.
Support Groups
Dream Life Out Loud periodically offers therapy and support groups throughout the fall and winter. Group offerings vary from year to year and may focus on topics such as relationships, personal growth, life transitions, parenting, or community healing. Some groups may be eligible for insurance reimbursement while others are offered as private-pay programs. Join our mailing list or indicate your interest on this form to be notified when new groups become available.
Therapy Intensives
Therapy Intensives are extended, private-pay therapy sessions designed for individuals, couples, and families seeking focused support and meaningful progress in a shorter period of time. Rather than meeting weekly over several months, intensives provide dedicated time to explore patterns, build skills, navigate challenges, and create a plan for moving forward.

Intensives may be a good fit for relationship concerns, communication challenges, life transitions, family conflict, burnout, premarital preparation, discernment, or individuals and couples looking to accelerate their therapeutic work. Sessions are offered in extended formats ranging from half-day to multi-day experiences and are customized to your goals and needs.

*Note: Please note that Therapy Intensives are not billed through insurance and are offered as a private-pay service.
Your Information
Your Name

First NameLast Name
Date of Birth

MonthDayYear
Gender Pronouns
Contact Number:
Format: (000) 000-0000.
E-mail
example@example.com
Your Partner's Information
Enter your partner's name:

First NameLast Name
Enter your partner's email address:
example@example.com
Enter your partners phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Your Family's Information
Who would participate? (e.g. Mom Dad, 27 year old son, etc.)
Please enter family members' name and email address:
Your Child's Information
Enter the child's name:

First NameLast Name
If the client is a minor, what is their date of birth?

MonthDayYear
Date
Child's Gender Pronouns
What school do they attend?
What grade are they in?
Enter the parent/guardian's name:

First NameLast Name
Relationship to child?
Parent/guardian email:
example@example.com
Parent/Guardian Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Does anyone else have legal decision-making authority for the child?

Other
What strengths, interests, or qualities would you like us to know about your child?
What state are you located in?
How did you hear about our services?
Referring Provider's Name

First NameLast Name
When are you hoping to begin services?
How Can We Help?
Tell us what brings you to Dream Life Out Loud at this time? What challenges are you interested in working on with a provider?
What is motivating your interest in an intensive rather than ongoing weekly or bi-weekly therapy?
What brings you to relational therapy?

Other
What is your primary concern?

Other
What outcome are you hoping to achieve for your relationship?

Other
Have you previously participated in therapy before?

Other
Payment For Services
How will you be paying for services?

Other
Insurance & Payment Information
Dream Life Out Loud, PLLC currently accepts several insurance plans for psychotherapy services. Because insurance networks can be listed under different parent companies, plan names, or administrator names, we review each client’s insurance information before services begin.

Please note that insurance participation may vary by clinician and plan type. Our Client Care Team will review your insurance information and help determine whether your benefits appear to be in-network with Dream Life Out Loud.

Insurance verification is not a guarantee of coverage or payment. Clients are responsible for any copays, deductibles, coinsurance, denied claims, non-covered services, or balances not paid by insurance.

For insurance plans where we are out-of-network, clients may be eligible for out-of-network reimbursement. Upon request, we can provide a Superbill for you to submit directly to your insurance carrier.

We accept all major credit cards, as well as Health Savings Account (HSA) and Flexible Spending Account (FSA) cards.

Payment is due at the time of service.
Using Out-of-Network Benefits

Many insurance plans offer out-of-network reimbursement for psychotherapy services. If Dream Life Out Loud is not in-network with your insurance provider, you may choose to pay for services directly and request a Superbill for submission to your insurance company.

While reimbursement is never guaranteed, many clients receive partial reimbursement depending on their individual plan. We recommend contacting your insurance carrier to better understand your out-of-network mental health benefits, deductible requirements, and reimbursement rates.

We accept all major credit cards, as well as Health Savings Account (HSA) and Flexible Spending Account (FSA) cards.

Payment is due at the time of service.
Private Pay Services

Clients may choose to pay for services directly rather than use their health insurance benefits.

Clients who elect not to use available insurance benefits—or who choose to participate in a therapy intensive—will be asked to sign an acknowledgment indicating that they are voluntarily declining insurance billing (when applicable) and accepting financial responsibility for services.

Private pay may be a good option for clients who value increased privacy, wish to avoid a mental health diagnosis being submitted to insurance, desire greater flexibility in their treatment, or are seeking a more focused and immersive therapeutic experience through a therapy intensive.

We accept all major credit cards, as well as Health Savings Account (HSA) and Flexible Spending Account (FSA) cards.

Payment is due at the time of service.
Therapy Access Funding
Dream Life Out Loud proudly welcomes clients utilizing mental health funding through programs such as the Washington Therapy Fund Foundation and The Loveland Foundation.

If you have received a therapy voucher or funding award, please let us know as part of your inquiry. Our team will work with you to verify eligibility, review available services, and discuss any remaining financial responsibility prior to beginning treatment.

We believe access to quality mental health care matters and are committed to helping clients navigate available funding resources whenever possible.
Couples and Family Therapy & Insurance

Many clients are surprised to learn that couples therapy is not always covered by health insurance plans. While some plans may provide coverage when medical necessity criteria are met, coverage for relationship-focused therapy varies significantly by insurer and individual plan.

Because benefits differ from plan to plan, we encourage clients seeking couples therapy to contact their insurance provider directly to verify eligibility and coverage prior to beginning services.

Questions you may wish to ask your insurance company include:

• Do my benefits cover couples or marriage counseling?
• Is a mental health diagnosis required for coverage?
• Are there limitations on relationship-focused therapy services?
• What is my copay, deductible, or coinsurance responsibility?

Our team is happy to help you understand your options, but we strongly encourage clients to verify coverage directly with their insurance carrier.
These are the plans we are in-network with, please select your health insurance provider:
If you do not see your health insurance plan on the list, please select other and share your current health insurance provider. Our team will notify you when we're a contracted practice with your plan.
Who is your medical health insurance provider
Are you the policy holder?

Other
Policyholder’s Full Name
Policyholder’s Date of Birth

MonthDayYear
Date
Relationship to Policyholder
Member/Subscriber ID
Group Number
Upload a Copy of Your Insurance Card

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Client Preferences
Who would you feel most comfortable working with?

Other
Preferred Intensive Format?

Other
Are you interested in:
What made you reach out to Dream Life Out Loud?
Join the Waitlist

As Dream Life Out Loud continues to grow, we invite you to join our Priority Contact List to learn about therapy intensives, future clinician openings, and expanded wellness services.
Would you like to:

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Availability Preferences
Are you interested in virtual or in person services?
Preferred appointment times?

Other
What days work best?

Other
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Services

Your Information

Your Partner's Information

Your Family's Information

Your Child's Information

How Can We Help?

Payment For Services

Client Preferences

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