PRO TIP:  Take Pictures of Drivers License/ID (front & back) & Health Insurance Card/s (front & back) BEFORE filling out this form. 

​

*Request My Appointment & Verify My Insurance Form

​

This *required form is for Prospect Clients & Returning Clients to gather basic information such as reason/s for seeking treatment to determine Client-Clinician Match; Preferred Days/Times for Therapy Session/s, and Health Insurance/Private Pay Information. Please submit this form so we may promptly provide you with a Benefits Quote / "Good Faith" Estimate and schedule your Intake Appointment according to your preferences.

 

What Happens Next? 

​

You'll receive a Welcome Text Message with:

​

• Your Intake Appointment Details 

• Benefits Quote or "Good Faith" Estimate

• Intake Forms 

• Link to Virtual Waiting Room

​

To confirm the Intake Appointment, simply reply with "C".  

​​​

Warm Regards, 

Melissa E. Mendoza, LMSW

​​​​​​​🔗LinkTree Link:  https://linktr.ee/pinkpsy

​

*If not a match we will provide referrals.

**No obligation or cancellation fees if you decide not to proceed with the session based on the provided benefits quote.

***All Forms are Mobile Friendly / Electronic Forms that are HIPPA compliant and ENCRYPTED which means your information is safe and secure.