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 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. 


Insurance Form

Client Name *
Client Name
If seeking relationship or family counseling, please complete form for the primary insurance holder.
Client Date of Birth *
Client Date of Birth
Client Address *
Client Address
Client Phone Number *
Client Phone Number
Current Legal Gender *
According to Insurance Company Records
Include letters and numbers if present on insurance card.
Are you the policy holder? *
*Only complete if you are not the policy holder.
Policy Holder Date of Birth
Policy Holder Date of Birth
*Only complete if you are not the policy holder.
*Only complete if you are not the policy holder.
Policy Holder Address
Policy Holder Address
*Only complete if you are not the policy holder.
Policy Holder Phone Number
Policy Holder Phone Number
*Only complete if you are not the policy holder.