NEW CLIENT PAPERWORK & PAYMENT INFORMATION

Please print, read through, and fill out the appropriate forms and bring them with you to your first therapy appointment

Studio For ChangeĀ® accepts out-of-pocket payments and the rates are discussed and set directly with your therapist. We have contracted with BC/BS PPO, so clients with this coverage are only responsible for co-payment and unmet deductibles. “Out of network” benefits may apply through many other insurance carriers. Please contact us to find out more about rates and payment accommodations for your specific circumstances.

Insurance Benefit Verification

:

:

: 123-456-5555

:

Are you already in contact or working with a Studio For Change therapist?
If YES which one:

:

: Group Number:

Insurance Provider Customer Service Phone Number (on back of insurance card):