PSYCHOTHERAPY CENTER OF WAUNAKEE
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Name
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First
Last
Full name of potential client
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Birthdate of client
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Email
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Phone number
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I'm looking to . . .
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Be added to the waitlist with any therapist
Be added to the waitlist with a female therapist
Be added to the waitlist with a male therapist
Be added to the couples waitlist
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Insurance member ID
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Please provide your insurance ID. **If not available or you are helping a patient and do not have access to it, please type all zeros in. Thanks.
Insurance Provider
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Dean
Quartz
Anthem BCBS
The Alliance
Medicaid/Badger Care
GHC
iCare
UMR
Cigna
United Healthcare
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Comments
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Please include a brief description of why you are seeking therapy and how we can best reach you. We are looking forward to meeting you.
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Home
About
Services
Investment
Contact
Resources
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Parent coaching