Fill out this form to request an appointment for yourself. We look forward to meeting you!

Please note: Our practice is primarily private pay. We accept Lyra Health and use a company called Headway to bill Aetna for individual appointments. Our insurance contracts are for individual therapy sessions only. Clients cannot use insurance for group sessions. Otherwise, we are considered out-of-network.

To use your out-of-network insurance benefits, you would pay for services at the time of the session and seek potential reimbursement from your insurance. Please feel free to use our Insurance Benefits Checker to check your out-of-network benefits. We encourage you to call your insurance and use our Tips for Using Out-of-Network Benefits sheet to confirm that these numbers are accurate.

How did you hear about us? *

First Name *

Last Name *

Client's Pronouns (she/her; he/his; they/them; ze/hir/zir)

Email *

Phone *

What is your preferred contact method? *

Date of birth *

MM-DD-YYYY

Age

Which type of services are you interested in? *

Please select your primary reason for seeking services *

Please briefly describe the reason for seeking services. *

Preferred Location *

If you are seeking telehealth services, please select the state in which you will be physically located during your sessions

Preferred Appt Time *

8AM-12PM

12PM-4PM

4PM-8PM

Other notes regarding your availability

Who will be paying for your services? (This helps us make sure the right people get the right information) *

Myself

Someone else

We accept Lyra Health and some Aetna plans. We are otherwise considered an out-of-network provider. What that means is that you would pay for services at the time of your session and seek potential reimbursement from your insurance. It’s important to look at your benefits if you will be seeking reimbursement. We’ve had clients who receive significant reimbursement and some that have no benefits. You can always use an HSA (health savings account) or FSA (flexible spending account) card for services.

To see if you qualify for out-of-network reimbursement for our services, please use the tool here: https://www.cincinnaticenterfordbt.com/therapy-services/fees/

Primary Insurance Provider *

Aetna Inquiries Only: We use a company called Headway to be able to bill Aetna for individual therapy appointments. Headway manages everything related to payments and insurance to make things as easy as possible for you. We will help you make sure we accept your plan and check your benefits. The Headway team will reach out via email to help you set up your account and add your insurance and payment details.

Would you like us to help you look up your out-of-network insurance benefits?

Yes

Thank you for completing this appointment request form! We will contact you soon to match you with the best therapist. If you'd like to go ahead and schedule with a therapist yourself, you can do so at the link on the next page after you submit this form.

When is the best time to reach you?

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