Request An Appointment

Name *

First Name

Last Name

Phone *

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Confirm Your Phone Number *

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Date of Birth *

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Insurance Fraud Acknowledgement

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

I verify that ALL insurance information provided is accurate.

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.