Akua Family Therapy | 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

State

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Administrative

Inquiry reason

Referral source

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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

Using health insurance for therapy requires a mental health diagnosis, which becomes part of your medical record and may be reviewed by your insurance provider. Clients paying out of pocket are not required to receive a diagnosis unless clinically necessary. Please verify coverage with your insurance provider before beginning therapy. Akua Family Therapy does not accept insurance for Anger Management Assessments, Coparenting Therapy, or adults working with a pre-licensed or intern therapist. Clients seeking these services must pay out-of-pocket at the established rates.

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Insurance card upload

Upload a photo of your insurance card

Only one licensed therapist currently accepts insurance for adult services. Would you be open to private-pay sessions with a supervised pre-licensed therapist?

YES, I AM ABLE TO PAY OUT OF POCKET. NO, WE ARE NOT ABLE TO PAY OUT OF POCKET.

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend (Sorry our office is closed on weekends/no availability)

Preferred clinician

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Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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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.