Insurance verification form

We want therapy to be accessible and stress-free, starting with your insurance. Use the form below to verify your benefits quickly and securely. Our team will review your information and contact you with a clear explanation of your coverage and next steps so you can focus on what matters most: your mental health.

Name

First Name

Last Name

Date of Birth

YYYY

Phone

Country

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Session

Reason for visit

Other Reason for visit

Insurance Provider

Member ID Number on Your Card

Insurance Provider Phone Number

Other Insurance Provider Phone Number

(###)

###

####

How Did You Hear About Us?

Are You the Policy Holder on the Account?

If not, please indicate the name, gender, and date of birth of the policy holder, and their relationship to you.

Do you have a Secondary Insurance Plan?

If so, please provide the Insurance Carrier and Member ID number for that policy.

See our Privacy Policy at https://www.theralisten.com/privacy-policy/

for details on how we handle your information. We never share or sell your opt-in information.

Yes, I agree to receive text messages from TheraListen at 516-875-2075. Message frequency varies and may include appointment reminder messages and data rates may apply. Opt out at any time by replying 'stop' or 'unsubscribe'.

No, I do not want to receive messages from TheraListen