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.
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 Kristina 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 Twenty-Five dollars ($125) for return visit appointments.