Today's Date:

MM

DD

YYYY

Client DoB:

MM

DD

YYYY

Client Name:

First Name

Last Name

Phone:

(###)

###

####

Type of Service Requested

Please select all that apply.

Individual Counseling

Comprehensive Psychological Evaluation

Other

Preferred Service Location

Perry, NY Office

Wellsville, NY Office

Telehealth

Payment Options (select below):

We accept private pay and are in-network with the health insurance plans listed below (you can verify your in-network coverage by logging into your insurance provider’s website or calling the customer service number on the back of your insurance card). Unfortunately, we do not accept Medicaid at this time. If you have questions about coverage or payment options, please contact us.

Highmark Blue Cross Blue Shield

Excellus Blue Cross Blue Shield

Independent Health

MVP Healthcare

Private Pay ($175 per session)

Preferred Day/Time for Intake Call:

Tuesday 9 am - 11 am

Tuesday 12 pm - 2 pm

Tuesday 3 pm - 5 pm

Thursday 9 am - 11 am

Thursday 12 pm - 2 pm

Thursday 3 pm - 5 pm