Other people involved Family Therapy Names and Ages (optional) ▶ Listen to this question List the first and last names of additional family therapy participants, followed by their date of birth
Partner's Gender Identity (optional) ▶ Listen to this question — Select — Man Woman Nonbinary Prefer to self describe Decline to say
Partner's Administrative Sex (optional) ▶ Listen to this question — Select — Female Male X This is necessary to submit claims to your insurance. Please provide the administrative sex on record with your insurance company.
What is your relationship to the patient (optional) ▶ Listen to this question — Select — Myself. Student A family member, friend, or co-worker. A patient or client from my healthcare organization. A member receiving benefits from my health insurance company.
Will another adult be involved in scheduling, billing discussions, etc? (optional) ▶ Listen to this question — Select — Yes No
Does the patient require assistance setting up services and completing paperwork due to a medical condition? (optional) ▶ Listen to this question — Select — Yes No
Contact and location State (optional) ▶ Listen to this question — Select — Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington D.C. Please provide which state the patient will primarily be in during sessions. Sessions are teletherapy by default. In-person sessions can only be provided at our North Chesterfield, VA location and are dependent on availability.
Partner’s State (optional) ▶ Listen to this question — Select — Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia (Washington, D.C.) Provide the state your partner will primarily be in during sessions. Sessions are teletherapy by default. Contact our team about in-person availability.
Insurance and payment EAP Name (optional) ▶ Listen to this question — Select — .Other or I don't know. (Write-in below) Aetna EAP Anthem EAP Beacon EAP Cigna/Evernorth EAP Compsych Curalinc EAP Humana EAP Magellan EAP Optima EAP United Healthcare/Optum EAP
Insurance Provider of Prospective Client (optional) ▶ Listen to this question — Select — Self-pay (not using insurance) AARP Medicare Supplement Plans insured by United Healthcare Aetna Commercial Aetna Better Health of Virginia Medicaid Aetna Better Health of Virginia Medicare Anthem Blue Cross Blue Shield Anthem EAP Anthem Federal Employees Anthem Healthkeepers HMO Anthem Healthkeepers Plus Medicaid Anthem Healthkeepers Plus Medicare CareFirst Blue Cross Blue Shield Centerstone Solutions Christian Brothers Services Cigna/Evernorth Cigna Medicare Advantage ComPsych Curalinc GEHA Humana Humana Medicaid Humana Medicare Independence Administrators Kaiser Permanente Magellan Commercial Magellan Complete Care Medicaid Molina Optima/Sentara Health Plan Optima/Sentara Health Medicaid Optum Community Care through Veteran Affairs Southern Health Texas Blue Cross Blue Shield Texas Medicare Tricare/Humana Military UMR United Healthcare/Optum United Healthcare/Optum Medicaid VA Medicare Part B Virginia Premier Health Plans Virginia Premier Medicaid Other Note: recent changes to Medicare's telemedicine coverage do not affect mental health services.
Secondary Insurance Provider of Prospective Client (optional) ▶ Listen to this question — Select — Self-pay (not using insurance) AARP Medicare Supplement Plans insured by United Healthcare Aetna Commercial Aetna Better Health of Virginia Medicaid Aetna Better Health of Virginia Medicare Anthem Blue Cross Blue Shield Anthem EAP Anthem Federal Employees Anthem Healthkeepers HMO Anthem Healthkeepers Plus Medicaid Anthem Healthkeepers Plus Medicare CareFirst Blue Cross Blue Shield Centerstone Solutions Christian Brothers Services Cigna/Evernorth Cigna Medicare Advantage ComPsych Curalinc GEHA Humana Independence Administrators Kaiser Permanente Magellan Commercial Magellan Complete Care Medicaid Molina Optima/Sentara Health Plan Optima/Sentara Health Medicaid Optum Community Care through Veteran Affairs Southern Health Texas Blue Cross Blue Shield Texas Medicare Tricare / Humana Military Tufts Health Plan UMR United Healthcare/Optum United Healthcare/Optum Medicaid VA Medicare Part B Virginia Premier Health Plans Virginia Premier Medicaid Other
