Request An Appointment

Complete the form below. (Copy)

Complete the paperwork. (Copy)

Schedule An Appointment (Copy)

Wellness & Courage accepts:

Ambetter
Blue Cross Blue Shield (not Federal BCBS)
United Healthcare, UMR, & GEHA (not All Savers)
Municipal Health
Qual Choice
Insurances that we are not able to accept:
- Federal Blue Cross Blue Shield
- Medipak (BCBS Medicare)
- UHC All Savers
- Traditional Medicare
- UHC Medicare
- UHC (US Health Group)
- UHC Golden Rule
- Traditional Medicaid
- Any other insurance that is not listed in the list above.
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, AMBETTER, QUALCHOICE, UHC, UMR, AND MUNICIPAL HEALTH BENEFITS PROGRAM. ALL OTHER INSURANCES WILL BE CONSIDERED PRIVATE PAY. Insurances that we are not able to accept: Federal Blue Cross Blue Shield UHC or UMR All Savers Traditional Medicare UHC Medicare UHC (US Health Group) UHC Golden Rule Traditional Medicaid Any other insurance that is not listed in our list of accepted insurances 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.

Member ID or Policy Number:

FOR PRIVATE PAY, JUST MARK WRITE "NA". 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

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