Please fill out this form if you are requesting an appointment for your child or for someone else for whom you are a guardian. We will contact you soon with next steps to find a therapist. If the child/dependent is over the age of 18, we will need to speak with them to schedule. Please have them complete this form. 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? *

Parent/Guardian's First Name *

Parent/ Guardian's Last Name *

Parent/Guardian's Email *

Parent/Guardian's Phone *

Preferred Contact Method *

Would you like to list an additional parent/guardian at this time?

Dependents First Name *

Dependent's Last Name *

What Are Your Child's Pronouns (e.g., she/her, he/him, they/them, ze/hir/zir)?

Child’s Email

Child’s Phone

Enter Your Child's Date of Birth *

MM-DD-YYYY

Child's Age

Child's school

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

Please select your primary reason for seeking services *

Please describe in your own words your reason for seeking therapy for your child: *

Preferred Location *

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

What times is your child available for services? *

8AM-12PM

12PM-4PM

4PM-8PM

Any notes you'd like us to know about your child's 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

Primary Subscriber

Primary Subscriber Date of Birth

Insurance Member ID

Insurance Group ID

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 soWhen is the best time to re... at the link on the next page after you submit this form.

When is the best time to reach you?

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