Most Major Insurances Accepted

PRO TIP:  Take Pictures of Drivers License/ID (front & back) & Health Insurance Card/s (front & back) BEFORE filling out this form. 

*APPOINTMENT REQUEST FORM

This required form is for Prospect Clients & Returning Clients to gather basic information such as reason/s for seeking treatment to determine Client-Clinician Match; Preferred Days/Times for Therapy Session/s, and Health Insurance/Private Pay Information.  Please submit this form so we may promptly provide you with a Benefits Quote / "Good Faith" Estimate and schedule your Intake Appointment according to your preferences.

What Happens Next? 

Upon receipt of the Appointment Request Form, we will promptly review your submission. **If an appropriate Client-Clinician match, we will subsequently provide you with a Welcome Message containing the following: 

• Intake Appointment Day/Time
• Benefits Quote / "Good Faith" Estimate
• Intake Forms 
• Virtual Waiting Room Link

Simply reply "C" to Confirm Intake Appointment.  

Yes, scheduling is really that simple!

Thank you, 

Melissa E. Mendoza, LMSW

The Pink Positive Psychology Team

🔗LinkTree Link:  https://linktr.ee/pinkpsy

All Forms are Mobile Friendly / Electronic Forms that are HIPPA compliant and ENCRYPTED which means your information is safe and secure.

*This is a required from. 

**If you are not a match we will provide you with referrals. 

***Returning clients are previous clients that have not been seen for more than 2-months and or current clients with NEW Health Insurance.