If you are a referring partner or provider, please fill out this form. NOTE: Your client's email is required so we can email intake forms to the client you are referring right away. Thank 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? *

What agency/office are you referring from? *

What is your email address? *

What is your full name? *

What is your phone number? *

Are you referring a Dependent whose Parent/Guardian is the main point of contact? *

Primary Client or Guardian's First Name *

Primary Client or Guardian's Last Name *

Primary Client or Guardian's Email *

Primary Client or Guardian's Phone *

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

Primary Contact's Preferred Method of Contact *

Enter the Client's Date of Birth *

Client's Age

Which type of services do you believe this client would benefit from? *

Select the primary reason that has led to this referral *

Please briefly describe the reason for the referral *

Preferred Location *

If the client is interested in telehealth services, please select the state in which they will be physically located during sessions

Preferred Appt Time

8AM-12PM

12PM-4PM

4PM-8PM

Other notes regarding their availability

Is this referral aware that we are self-pay other than accepting Lyra Health and some Aetna plans for individual therapy appointments? If clients want to use their out-of-network insurance benefits, they would pay the full fee at the time of the session and seek potential reimbursement from their insurance. We are happy to provide superbills or submit claims on their behalf through Thrizer. *

Yes

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

Yes

Primary Insurance Provider *

Primary Subscriber *

Primary Subscriber Date of Birth *

Insurance Member ID *

Insurance Group ID *

Thank you so much for thinking of us and trusting us with this client's care. Please feel free to contact us at 513-268-8306 or [email protected] if you'd like to touch base or discuss further.

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