Endurance Counseling | SimplePractice

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

Please share a brief summary of the reason for seeking therapy and/or goals for therapy (think just two sentences or less – we will discuss this in detail later, I just want to make sure I’m also a good fit for your needs).

Limited to 600 characters

Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Payment Source

I am in-network with Anthem Blue Cross Blue Shield, United Healthcare/Optum, Aetna, and Cigna. I do not accept Medicaid or Medicare plans. For in-network insurance clients, I will verify benefits as a courtesy, but it’s a good idea to check directly with your insurance provider too. A quote or pre-authorization doesn’t guarantee payment, and final coverage decisions depend on your plan at the time of service. For out-of-network clients, I can provide a superbill that you may submit to your insurance for possible reimbursement, but you will indicate "Self Pay" here. You are strongly encouraged to check your own out of network insurance coverage, as reimbursement is not guaranteed.

Insurance card upload

Upload a photo of your insurance card

Have you read and understand the following policies?

I understand that appointments canceled with less than 24 hours' notice may be subject to an $80 cancellation fee, unless documentation of an emergency is provided. I understand that a credit card is required to be kept on file before treatment begins for copays, coinsurance, and applicable cancellation fees.

Yes No

Client Preferences

Preferred appointment times

We'll do our best to accommodate your preferences based on current availability.

Weekday Morning Weekday Afternoon Weekday Evening Weekend Flexible

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, additional information about your availability, etc.

Limited to 600 characters

What to Expect Next

If we appear to be a good fit, I will verify your insurance (if applicable) and contact you to schedule your first appointment. You will then receive an invitation to complete your intake paperwork through SimplePractice, my secure client portal, where you can view and request appointments. If we do not appear to be a good fit for any reason, I will contact you via email to let you know.

Got it! I understand what to expect next. I have questions about the next steps. Please contact me.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.