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Contact Us: 757-756-8741
Fax: 757-500-8075

We believe Nurturing, Education and Wisdom will contribute to your process of growth & self-discovery

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Client Screening Form

Please fill out the following form to help us understand your therapy needs and verify your insurance prior to the intake process.

Client's First Name

Client' Last Name

Email Address

Date of Birth

Client's Phone Number

The following insurance providers are accepted. Please select the following health insurance provider *

Sentara (Formerly Optima)

Magellan

United Healthcare

Optum

Cigna

Aetna

Anthem BCBS

Care First

Private Pay

Medicaid

Lyra

Have you received therapy in the past? *

No

Yes

If you answered yes, please elaborate when therapy was provided and the reason for therapy

Person Completing form name & telephone number?

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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