Empowered Healing | SimplePractice

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

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.

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Preferred modality

Do you consent to the use of AI in the delivery of your care?

Your clinician may use AI tools (such as using AI to generate an intake summary) to help support your care. Your information is protected under HIPAA and anything generated by AI is always reviewed by your clinician. AI does not make decisions about your care. You can withdraw this consent at any time by contacting your provider without it impacting the care you receive.

Yes No

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.