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. 


PLEASE READ CAREFULLY:  This *REQUIRED form is for Current Clients with NEW INSURANCE to gather basic information such as reason/s for seeking treatment to prove medical necessity; to ADD Possible New Additional Payment Method(s) i.e. NEW Health Savings Account, NEW Flexible Spending Account, etc.; to Update Day/Time of Appointments, if applicable, or we may need to schedule you to come in for your NEW Intake Appointment on a different/day/time than normal contingent on how long it takes to verify your NEW Insurance hence the sooner you submit your NEW Health Insurance/s information the better and ultimately to obtain your NEW Health Insurance/s so we may promptly provide you with a NEW Benefits Quote/s in order to schedule your Intake Appointment based on noted preference. 

What Happens Next? 

Upon receipt of the NEW INSURANCE APPOINTMENT REQUEST FORM, **if we accept your insurance, we will promptly review your submission and send you a Welcome Message containing the following: 

  • New Intake Appointment Day/Time 
  • New Benefits Quote 
  • *Legally Required Intake Forms
  • *Insurance Required Assessments
  • Virtual Waiting Room Link

*Please fill out ALL aforementioned Forms/Assessments 24-48 hours BEFORE Intake Session. 

Simply reply "C" to Confirm Intake Appointment.  

Yes, scheduling with NEW Insurance is really that simple!

Thank you, 

Melissa E. Mendoza, LMSW

The Pink Positive Psychology Team

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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 we do NOT accept your insurance we will provide you with referrals.  If you would like to pay out of pocket if we do not accept your insurance please let us know and we provide you with a "Good Faith" estimate for private pay session(s).