Name *

First Name

Last Name

Phone *

(###)

###

####

What services are you interested in? *

EMDR Weekly or Bi-Weekly Sessions

EMDR Intensive Sessions 4+ hours (accelerated therapy sessions for quicker results)

If you will be utilizing insurance for sessions, please check the box indicating which insurance. *

We are in-network with the insurances listed.

UnitedHealthCare

Medica

UMR

TriCare (Non-Participating Provider)

Out-of-Network/Self-pay

If you will NOT be utilizing insurance or would like to utilize Out-of-Network benefits, please check appropriate box below.

Check out the HIPPA compliant Insurance Benefit checker BELOW!! (If you have an out-of-network insurance, you will be responsible for the full amount of session, and we will submit a claim to your insurance on your behalf for possible reimbursement) Please note: We DO NOT accept MN State insurance or Medicare.

Out-of-Network/Self-Pay (I will be paying for each session out of pocket)

Veteran Resilience Project (www.veteranresilienceproject.org)

MN Fire Network EAP

N/A