Empowered Healing | SimplePractice

Empowered Healing Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Reason for care

What is the reason for seeking care?

What kind of care is being sought?

Psychotherapy Medical Nutrition Services Both

If seeking services for mental health therapy what is your history of treatment?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

If you are seeking services for medical nutrition therapy, have you ever worked with a Registered Dietitian before?

Administrative

Inquiry reason

How did you find out about Empowered Healing?

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Payment method

How do you plan to pay?

Insurance details and payment details

We are only in network with UHC and Anthem BCBS. If you are out of network we can provide you with a superbill to submit to your insurance for possible reimbursement.

United Health Care Anthem BCBS Private pay Private Pay with Superbill

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

We are open M-TH from 9-5. Please let us know days and times that you prefer.

Limited to 600 characters

Preferred clinician

Select a clinician from the list

No results found.

Preferred modality

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.