First Name and Last Initial

First Name

Last Name

Phone *

(###)

###

####

I do not offer standard, hour long appointments. All sessions are a minimum of 90 minutes. *

I am interested in...

A one-time Intensive`to address a single event.

Weekly or bi-weekly 2-3 hour Trauma Reprocessing Sessions.

Ongoing Intensives to address Complex Trauma

HPRP Evaluation

HPRP Group Therapy

Some of the services I offer are specialized and are not recognized by insurance carriers. For some sessions, out-of-network coverage might be possible; I can provide a superbill, which you can submit to your insurance company for reimbusement. Extended sessions are billed at $185/hr. The rate for Intensives is $225/hour. I accept credit cards, FSA and Care Credit (interest-free financing). *

I understand I will not be able to use insurance to cover any services with Jessica Bennett.

I understand that submitting a Superbill might not result in reimbursement.

I understand that if I have Medicare, I will not be ablt to submit a Superbill.

Do I have permission to text you from a HIPAA-Secure medical record-keeping software? *

Yes, you can text me.