Full Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred Method of Contact: *

Email

Phone Call

both Email and Phone Call

Preferred Day? *

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Time?

Morning 8 AM- 11 AM

Afternoon 12PM- 3PM

Evening 4 PM- 6 PM

Insurance Information *

What is your preferred method of payment? Please note: It is important to confirm with your insurance provider that OWR Therapy services are covered under your plan.

Insurance.

Self-Pay

Employee Assistance Program (EAP)

Service Selection

Please select the service(s) you are interested in:

Individual Therapy

Couples and Relationship Therapy

Family Therapy

Perinatal Health Therapy (pregnancy & postpartum support)

Grief Counseling

Trauma Therapy

Stress Management

Location of Services

Preferred Therapy Setting:

In Office

Virtual

Service Terms *

By submitting this form, you acknowledge and agree to the following terms: Insurance Verification: OWR Therapy will not contact your insurance provider to confirm coverage for the selected therapy services. It will be the client's responsibility to confirm coverage. Any uncovered services or out-of-pocket expenses are the responsibility of the client. A credit card on file is required for lapsed insurance coverage, deductibles, copays, any late fees, or no-show fees acquired by the client. Cancellation Policy: You must provide at least 24 hours notice if you need to cancel or reschedule an appointment. Failure to do so may result in a cancellation fee. Confidentiality: All personal information and therapy sessions will remain confidential in accordance with HIPAA and ethical guidelines. Payment Responsibility: If services are not covered by your insurance, you agree to pay for the services rendered based on the agreed-upon rates discussed during your consultation. Informed Consent: By using OWR Therapy's services, you consent to participate in therapy and understand the therapeutic process may include discussing personal, sensitive topics that can bring emotional discomfort, which is a normal part of the healing process. Submit By submitting this form, you agree to the service terms and conditions, and to be contacted by OWR Therapy regarding the scheduling of your therapy sessions and verification of insurance coverage.

I have Read and understand all these terms.