Life With Baby Sessions Request
This request form is confidential. In compliance with the Health Portability and Accountability Act "HIPAA" (rule 104-91), please know that communications over the internet are not guaranteed to be secure.  There exists a possibility that information you include in this form can be intercepted and read by other parties besides the staff at RPC Austin. Please call us at 512-982-4116 if you prefer to request an appointment by phone.
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Name *
I am not currently in a crisis. (If you are currently in a crisis, please call 911 or go to the nearest ER) *
I understand that RPC Austin is not in-network with any commercial health insurance plans. *
We accept HSA/FSA card payments, and provide superbills for patients to request reimbursement from their health insurance provider. Patients are responsible for appointment payments. RPC Austin has no control over whether or not a health insurance plan will cover appointment costs. Please call our clinic if you would like more information.
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How were you referred to us?
How would you prefer to be contacted regarding this request? *
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If by phone or text, what is the best number to reach you at? *
If by phone call, when is the best time to call?
Do you consent to receiving voicemails regarding your request? *
What is the best email address to reach you at?
What is your date of birth?
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DD
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What gender do you identify with?
Is there a specific specialist that you would like to meet with? *
How many weeks pregnant are you? *
When do you hope to begin your LWB sessions? *
Is there anything else you want us to know?
Do you have a Life With Baby Gift Card?
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