Confirm Your Counseling Insurance Benefits

Please complete the form below to verify your insurance benefits/copayment. Once your benefits are confirmed, Headway (our insurance processor), will email you with a couple of forms necessary to process your insurance benefits. Please watch for their email.

If you have questions regarding this process, please use the notes section below or click here to send us a message. We are happy to help!

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Date of Birth *

Insurance Carrier *

Member ID *

Group Number (if applicable) *

Address on Record with insurance Provider *

Line 1

Line 2

City

State

Zip Code

Country

Front of Insurance Card *

Max file size: 20MB

Back of Insurance Card *

Max file size: 20MB

Notes (optional): *

Submit