Today's Date:

MM

DD

YYYY

Client DoB:

MM

DD

YYYY

Client Name:

First Name

Last Name

Phone:

(###)

###

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Type of Service Requested

Please select all that apply.

Individual Counseling

Comprehensive Psychological Evaluation

Other

Preferred Service Location

Perry, NY Office

Telehealth

Payment Options

In-network with the health insurance plans listed below (you can verify your in-network coverage by calling the customer service number on the back of your insurance card). Unfortunately, we do not accept Medicaid at this time. Private pay options available. 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

Univera Healthcare

Private Pay ($175 per hour)