Full Name *

Phone *

Email *

Total Family Yearly Income (pretax) *

Outstanding Debts (exclude mortgage/car) *

Number of Dependents *

Do you have health insurance? *

First, Last name on the policy

Date of Birth of Policy Holder

Member ID (including letters)

Insurance Company’s Name

Type of Therapy you are interested in *

If Other, please specify:

PLEASE NOTE

To qualify for a reduced fee for psychotherapy services, clients must maintain regular attendance. If your attendance becomes less frequent, your rate will return to the standard therapy fee.

Reduced fees are intended as a temporary arrangement. If your financial circumstances change—for example, a change in insurance benefits, a raise, or new employment that increases your ability to pay—you agree to notify us so we can adjust your fee accordingly. We review reduced fees every 3–6 months to ensure they remain appropriate.

AGREEMENT

I confirm that the information provided in this application is accurate and can be verified upon request. I agree to attend regular therapy appointments to maintain my reduced fee rate. I understand that reduced rates will no longer apply if my attendance becomes less frequent or if my financial circumstances improve, and I agree to notify my therapist of any such changes.

I consent to The Better You Institute checking my insurance to see what, if any, insurance coverage I recieve for their services