Women's Therapy California - Women's Online Therapy

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This website is HIPAA compliant. Your information is only shared with one of my insurance verification and billing companies (Alma or Headway). If you would like to submit your information directly to my billing company, please let me know!

I am interested in: *

Check all that apply

Soul Circle Therapy Workshop

Women's Mindfulness Group

Women's Process Group

Postpartum Support Group

Individual Therapy

Name *

First Name

Last Name

Email *

Phone *

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Date of birth *

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YYYY

Sex *

'Sex' is a required field on insurance claims. Please be sure to select the sex on file with your insurance provider.

Female

Male

Address associated with insurance *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Insurance provider *

This must be your primary insurance. Do not choose one on the list if it is a secondary insurance as my billing company will not be able to submit claims for secondary insurance. Thanks!

Member ID *

Group number *

Are you the primary subscriber? *

Yes. I'm enrolled individually or through my employer.

No. I'm enrolled through a parent, spouse, or domestic partner.

If enrolled through a parent, spouse, or domestic partner:

Full name of primary subscriber:

Primary subscriber date of birth

MM

DD

YYYY

Sex of primary subscriber

Female

Male

Relationship to client

Thank you! We should hear back from my insurance verification and billing partner in the next few business days and then we can discuss next steps!

-Kaci

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