Radical Healing Referral Requests
Thanks so much for your interest in working with a Radical Healing provider! If you’re hoping to start therapy immediately, please look at our therapists' individual profiles on our website so you have an idea of who you would like to work with. If you're not sure who you'd like to work with based on the therapists' profiles, our Program Manager will offer a recommendation of who might be a good fit for you. All therapists with availability can be found under the "Immediate Openings" section on our "About" page. If a provider is not listed under that section, they do not have current availability.

**We receive a very high volume of requests. As of 11/25/22, several of our providers still have openings, however there are many prospective patients currently in the consultation process. We are expecting to move to a waitlist system very soon. If you do not want to be added to our waitlist, please indicate that in the "additional comments" section. Thank you!**

We are accepting new insurance-based patients who have Cigna, Aetna, United, or BCBS (all plans except Blue Home, Blue Value, and Blue Local). We are also accepting self-pay patients at the following rates: Master's Associate License Clinicians: $135/session, Master's Level Fully Licensed Clinicians$150/session, PhD Clinicians: $175-250/session. Psychological testing/clinical assessments are not covered by insurance; the out-of-pockets costs range from $1,250-$3,600 on average due to the cost of materials and the length of time that the tests take (4 - 14 hours/average).

Please note that as of 8/15/22 we do not have any providers with sliding scale or pro bono spots available. If you're looking for sliding scale/pro bono services, you're welcome to submit this form to join our specific sliding scale/pro bono waitlist. If additional spots become available, we will reach out to people on the waitlist in the order that the requests were received. Unfortunately, we aren't likely to have openings in the near future, so please seek other resources if you're in need of immediate support. If you would like assistance connecting to other resources, please mention this in the "additional comments" section.

Thank you again for your interest in our practice!
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Email *
What is your first and last name? Please include your legal first name in addition to your chosen name, if applicable. 

We will always personally address you as your chosen name, but require your legal name for billing/insurance purposes.
What is your phone number?
After your referral form has been received, our program manager will reach out to you via phone as soon as possible. Due to the high volume of requests we receive this may take up to 7 business days, though we aim for shorter response times whenever possible. We will make 3 attempts to reach you via phone. If we can't reach you after 3 attempts, your request will be made inactive. However, you're always welcome to reach out again in the future. Do you want us to leave a voicemail if we cannot reach you when we call?
What is your date of birth? What is your age?
What pronouns do you use? (e.g. they/them, she/her, he/his, all pronouns)
Do you identify as LGBTQ+?
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Do you identify as BIPOC?
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Do you have a preferred therapist or identities held by a therapist? (e.g. gender, race, name of therapist)
Preferred model of therapy, if any?
What general topics are you hoping to address in therapy?
When are you available to meet for sessions? Do you have any scheduling needs we should know about? (e.g. only available on weekends or evenings, reliance on public transportation, etc)
Do you want to meet with your therapist in-office or via Telehealth?
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How often would you like to meet with your therapist? *
Do you plan to use insurance? If so, who is your insurance provider and what plan do you have?

Do you plan to self-pay? If so, can you pay the full session fee or do you need a sliding scale rate? Please note that as of 8/15/22, we do not have any providers who have remaining pro bono or sliding scale availability.
If you're in need of sliding scale, how much can you reliably and reasonably afford to pay for each session?
If you are seeking Psychological Testing or a Clinical Assessment, which specific service are you looking for? Please note that these services are often not covered by insurance; out-of-pockets costs range from $1,250-$3,600 on average due to the cost of materials and the length of time that the tests take (4 - 14 hours/average).
For insurance-based patients: to expedite the intake process as much as possible, please email a copy of your insurance card (front and back) to our Program Manager, Claire Costello, after submitting this form. This will allow us to verify your insurance coverage before you become an official patient to minimize the possibility of receiving surprise charges. Even though we do our best to verify coverage as a courtesy, ultimately this is the responsibility of the patient. We advise all insurance-patients to verify their coverage themself because all denied charges are still the responsibility of the patient. The insurance card copy should be emailed to: claire@radicalhealing.us. Are you willing to send a copy of your insurance card to our PM?
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For insurance-based patients: Do you have multiple forms of insurance coverage (i.e. are you listed as a dependent on someone else's plan in addition to being a primary subscriber on your own plan?)
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Do you have any additional questions or comments that were not covered on this form?
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