Forms

Appointment Request Form

We’d love to get some information about your records. Please fill out this form to get started.

New Form

Name

First Name

Last Name

Email

Phone Number

Date Of Birth

MM

DD

YYYY

Subject

Insurance Service Provider/Cash

Insurance ID Number

Have you seen a Psychiatrist or Therapist before?

Yes

No

Psychiatrist/Therapist's Phone

(###)

###

####

Are you on any medication(s)?

Yes

No

Please list the medication(s)

Please provide any additional information you'd like us to know

Registration Paperwork

Must be completed prior to appointment

get started

Screen Forms

Must be completed prior to appointment

get started

Insurance

Kindly verify your health insurance coverage when you arrange your first visit. Our accepted Insurance Plans include the following:

Horizon
Cigna
Aetna
Medicare

Notice: While Vioral Health and Behavioral Services, LLP may make third-party referrals where and when deemed legally necessary, we are in no way affiliated to any of the organizations unless otherwise stated.

Appointment Cancellations

Please contact us within 48 hours of your scheduled appointment for any cancellations. You will be charged a $100 fee if you do not cancel within 48 hours’ notice. There is a $25 fee on all bounced checks in addition to fees charged by the bank.

Finances

Average cost per session: $125 - $350

Accepted Payment Methods: Cash and Check