Form Test (demo)

Let’s get some basic info

Please make sure what you enter matches what your insurer has on file. This helps us verify your coverage quickly and accurately.

Name(Required)

First Middle Last

Date of Birth(Required)

You must be 18 or older to book an appointment.

Phone(Required)

Email(Required)

Enter Email Confirm Email

Sex on file with insurer

Female

Male

We ask because insurance eligibility checks require the sex listed on your policy.

Gender identity

Please describe your gender identity

Primary address

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Referral source

How did you hear about us?(Required)

Referring doctor

Start typing your doctor's name and select them from the list if they're already in our system.

Please specify

Insurance information

We’ll verify your benefits before your appointment. If you do not currently have insurance, or we don’t accept your insurance at this time, please choose Self-pay below.

Payment type(Required)

I'll use insurance

Self-pay (out of pocket)

Your insurer(Required)

Other insurer (please specify)(Required)

Front of insurance card(Required)

Accepted file types: jpg, jpeg, png, pdf, heic, Max. file size: 10 MB.

Photos from your phone are fine. Make sure the text is readable.

Back of insurance card(Required)

Accepted file types: jpg, jpeg, png, pdf, heic, Max. file size: 10 MB.

Photos from your phone are fine. Make sure the text is readable.

Front of photo ID(Required)

Accepted file types: jpg, jpeg, png, pdf, heic, Max. file size: 10 MB.

A photo of your driver's license or other government-issued ID. Photos from your phone are fine — make sure the text is readable.

Back of photo ID(Required)

Accepted file types: jpg, jpeg, png, pdf, heic, Max. file size: 10 MB.

Photos from your phone are fine. Make sure the text is readable.

Member ID

Group number

Policyholder

Policyholder first name

Policyholder last name

Policyholder date of birth

Relationship to policyholder

Self-pay rates

Initial appointment (45-minute evaluation)$300

Follow-up appointment$125

Assessment (add-on · $195 total)+$70

You’ll receive confirmation of your rate before your appointment.

Self-pay acknowledgment(Required)

I understand I am choosing to pay out of pocket and that Mind Health Group will not bill insurance for this visit.

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Cancellation policy
We require at least 48 hours’ notice to cancel or reschedule. Cancellations made with less than 48 hours’ notice will be charged a $125 late cancellation fee, which must be paid before rescheduling. Missed (no-show) appointments will also be charged a $125 fee to the card on file. You can cancel or reschedule free of charge up to 48 hours before your appointment by calling the office or using the link in your confirmation email.

Policy acknowledgment(Required)

I have read and agree to the late cancellation and no-show policy.

Let’s get some basic info

Primary address

Referral source

Why are you seeking care?

Anything else you’d like us to know?

Insurance information

Choose your provider and time