Request An Appointment

Complete the form below.

Complete the paperwork.

Schedule An Appointment

Wellness & Courage Accepts:

Ambetter
Blue Cross Blue Shield (not Federal BCBS)
United Healthcare, UMR, & GEHA
Municipal Health
Qual Choice
Insurances that we are not able to accept:
Federal Blue Cross Blue Shield
Medicare and/or Medicare Supplement Plans
UHC or UMR All Savers
UHC (US Health Group)
UHC Golden Rule
Traditional Medicaid
Any other insurance that is not listed in our list of accepted insurances
IF YOU HAVE AN INSURANCE THAT WE DON’T TAKE OR HAVE A HIGH DEDUCTIBLE, WE OFFER REDUCED RATES OF $35 PER SESSION.
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PLEASE NOTE: If you have an OPEN POLICY insurance, your insurance must contact Wellness & Courage at info@wellnessandcourage.com to set up an agreement. Wellness & Courage DOES NOT contact Open Policy plans on behalf of the policy holder.

APPOINTMENT REQUEST FORM:

You will be contacted within 24 hours (or next business day).

Name

First Name

Last Name

Confirm Your Email Address

Phone

(###)

###

####

Confirm Your Phone Number

(###)

###

####

Date of Birth

YYYY

INSURANCE INFORMATION

IF YOU HAVE AN INSURANCE THAT WE DON’T TAKE OR HAVE A HIGH DEDUCTIBLE, WE OFFER REDUCED RATES OF $35 PER SESSION.

Insurance Provider

WELLNESS & COURAGE ONLY ACCEPTS BCBS (NOT FEDERAL BCBS), AMBETTER, QUALCHOICE, UHC & UMR (NOT AllSavers, Golden Rule, or UHC Medicare), AND MUNICIPAL HEALTH BENEFITS PROGRAM. ALL OTHER INSURANCES WILL BE CONSIDERED PRIVATE PAY. WE CANNOT ACCEPT TRADITIONAL MEDICAID OR MEDICARE. PLEASE NOTE: If you have an OPEN POLICY insurance, your insurance must contact Wellness & Courage at info@wellnessandcourage.com to set up an agreement. Wellness & Courage DOES NOT contact Open Policy plans on behalf of the policy holder.

Insurance Fraud Acknowledement

Providing false insurance information is considered insurance fraud, and is punishable by law. Examples of this include: -not reporting all insurance policies by which you are covered (i.e. only providing one insurance policy when you are covered by more than one policy) -giving false or misleading information or omitting important information, -Knowingly lying to obtain a benefit or advantage, or knowingly denying a benefit that is due

PRIMARY Member ID or Policy Number:

FOR PRIVATE PAY, JUST MARK WRITE "NA". BCBS & Ambetter insurances MUST include PREFIX (letters) before Member ID.

SECONDARY Member ID or Policy Number (IF APPLICABLE):

BCBS & Ambetter insurances MUST include PREFIX (letters) before Member ID.

LOCATION AND/OR THERAPIST PREFERENCE

Type of therapy requesting:

Location Preference:

Please be advised that there may be a waitlist at some locations. You will be provided the option to join the waitlist or get in sooner at one of our other locations.

Do you have a therapist preference?

Please be advised that there may be a waitlist. You will be provided the option to join the waitlist or get in sooner with another therapist.

DISCLAIMERS

ACKNOWLEDGEMENT OF SCHEDULING PROCESS:

STEP 1: COMPLETE THIS FORM TO REQUEST AN APPOINTMENT. STEP 2: WITHIN 24 HOURS OF FORM COMPLETION (or next business day), RECEIVE AN EMAIL INVITING YOU TO OUR CLIENT PORTAL, WHERE YOU'LL COMPLETE THE REQUIRED PAPERWORK. STEP 4: WITHIN 24 HOURS OF PAPERWORK COMPLETION (or next buseinss day) YOU WILL BE CONTACTED BY WENDY J. POOLE TO BE SCHEDULED.

Thank you. I look forward to hearing from you within 24 hours.

PRIVATE PAY RATES

IN ACCORDANCE WITH THE "NO SURPRISES" ACT, WELLNESS & COURAGE IS REQUIRED TO DISCLOSE PRIVATE PAY RATES PRIOR TO SCHEULING, EVEN IF YOU ARE USING INSURANCE.

I ACKNOWLEDGE THE PRIVATE PAY RATES: INITIAL ASSESSMENT: $200.00 INDIVIDUAL THERAPY: $160.00 FAMILY THERAPY OR COUPLES COUNSELING: $180.00

INSURANCE RATES:

RATES VARY BY INSURANCE. I UNDERSTAND THAT I WILL BE GIVEN AN ESTIMATE OF MY FINANCIAL RESPONSIBLITY DURING THE SCHEDULING PROCESS.

REFERRAL SOURCE

How did you hear about us?

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Request An Appointment

Wellness & Courage Accepts:

Insurances that we are not able to accept:

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