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 so we may promptly provide you with a Benefits Quote / "Good Faith" Estimate and schedule your Intake Appointment.
What Happens Next?
Upon receipt of 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!
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.