Your name: *

First Name

Last Name

I am interested in:

Individual therapy

Couples therapy

Family therapy

Your phone number: *

(###)

###

####

Ok to leave detailed voicemail at this number?

Yes

No

What is your preferred way for us to contact you?

Email

Phone

We are Out of Network with insurances, believing this enables us to provide the best care and ensure your privacy. *

I understand that I will be working with an Out of Network therapist, that I am responsible for all session fees at the time of service, and that I will submit my own claims to insurance for possible Out of Network reimbursement.

Do you have any type of Medicare insurance plan? *

GBH therapists do not participate with Medicare plans. Most therapists at GBH are opted out from Medicare altogether. You will be asked to sign a Medicare waiver and private contract to pay for sessions out of pocket, and will not receive super bills to submit to insurance.

Yes, I have a Medicare plan, and understand that I will waive Medicare benefits and enter a private contract for self-pay services at GBH.

No, I do not have any type of Medicare plan.

Do you have a Medicaid (state insurance) plan? *

GBH therapists do not participate with Medicaid. New Jersey Medicaid plans will not reimburse you for any GBH-provided services. *Medicaid laws may vary in other states, and so we do not work with Medicaid beneficiaries outside of New Jersey.

Yes, I have a NJ FamilyCare/Medicaid plan and understand that Medicaid will not reimburse me for any session fees.

No, I do not have a NJ FamilyCare/Medicaid plan.

Yes, I have a Medicaid plan in a state other than New Jersey.