Insurance Form

If you are interested in using insurance to pay for treatment, please complete and submit this form at least two business days prior to your initial appointment. If you are unable to complete this form, please contact the therapist with whom you are scheduled. If you do not complete the form or contact your therapist to make other arrangements, you will be responsible for the cost of the first session.

Insurance Release

In providing this information to Arbor Therapy Solutions, you are consenting for your insurance to be billed for your treatment with Arbor Therapy Solutions, Natasha Lewis-Grinwis, LMSW, CST, or Kris Lewis-Grinwis, LMSW. You are agreeing to pay all copayments and deductibles as directed by your insurance company, and per your behavioral health contract with said company. Should your insurance not cover treatment, you agree to pay for the treatment you receive, an amount not to exceed One Hundred Eighty-Five Dollars ($185) for an initial evaluation, or One Hundred Fifty ($150) for return visit appointments.

Insurance Form

Client Name

If seeking relationship or family counseling, please complete form for the primary insurance holder.

First Name

Last Name

Client Date of Birth

YYYY

Client Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Phone Number

(###)

###

####

Current Legal Gender

According to Insurance Company Records

Female

Male

Non-binary

Type of Insurance

If you chose 'other,' what is the name of your insurance company?

e.g. Cigna, HAP, Priority Health

Policy Number

Include letters and numbers if present on insurance card.

Group Number

Are you the policy holder?

Yes

If Yes, Name of Your Employer?

If No, Name of Policy Holder?

What is their relationship to you?

*Only complete if you are not the policy holder.

Policy Holder Date of Birth

*Only complete if you are not the policy holder.

YYYY

Policy Holder Employer

*Only complete if you are not the policy holder.

Policy Holder Address

*Only complete if you are not the policy holder.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Policy Holder Phone Number

*Only complete if you are not the policy holder.

(###)

###

####