Request for Appointment

REQUEST AN APPOINTMENT

Please take a few moments to complete this confidential form to request a virtual appointment. Your answers help us match you with the therapist best suited for your unique needs.
Crisis Notice: This form is not monitored for emergencies. If you are experiencing a crisis or emergency, please call 911 or go to your nearest emergency room.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Who Is Seeking Services?
Parent/Guardian Name

First NameLast Name
What Brings You to Therapy?
Payment Method
Insurance Company
Member ID & Group # - send copy of Insurance card
- Payment is due at the time of service.
- For out-of-network insurance, a superbill can be provided upon request.
- Missed appointments or cancellations with less than 24 hours’ notice may be subject to a fee.
- It is your responsibility to verify your insurance benefits.
I acknowledge and agree to the financial policy above.
I agree to email a copy of my ID and insurance card (front & back) to shireenmusleh@basiratherapy.com
I consent to be contacted regarding scheduling and services.
How did you hear about Basira Therapy PLLC?
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REQUEST AN APPOINTMENT