Flourish Psychology Contact Form

1
How should we address you? Please provide your full name.* This field is required.
First Name
Last Name
2
What is your preferred email address?* This field is required.
example@example.com
3
What is your preferred phone number?* This field is required.
e.g (734) 267 - 7532
4
What is Your Address? (optional)
Street Address
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5
Is this your first time seeking therapy?* This field is required.
YESNO
6
What state are you located in?* This field is required.
7
What areas would you like to work on in therapy?Choose as many as you'd like
Anxiety
Art Therapy
Body Image and Disordered Eating
Brainspotting
Cognitive Behavioral Therapy (CBT)
Dialectical Behavioral Therapy (DBT)
Depression Therapy
Grief & Loss
Infertility
LGBTQ Affirming Care
Relationship Issues & Couple's Counseling
Self Care & Balance
Self Esteem & Confidence
Trauma Therapy
Work Success
8
Wellness has no finish line and we don't want you to be limited by an insurance policy. * This field is required.*The average cost to see a licensed clinician at Flourish Psychology is $275. You may be reimbursed by your insurance company for a percentage of the cost.* Here are some tips to find out more about your out-of-network benefits. Contact the member services number on the back of your insurance card and ask the following: 1. What are my out-of-network mental health benefits? 2. Do I have a deductible? What is it? 3. What percent of the therapist’s fee is covered with my out-of-network benefits and at what rate? 4. Is there a session cap per year? 5. How do I get reimbursed? 6. How do I submit claims? *Flourish Psychology does not guarantee you will be reimbursed for services through your insurance company.*
I have out-of-network benefits and would like to proceed
I'd prefer to be billed directly
9
Please provide any additional details you wish to share with us here.
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Ok
10
How did you hear about us?
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Other
11
Would you like to be part of the Flourish Psychology family and receive mental health tips and good news moments?
YESNO
12
Please verify that you are human* This field is required.
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