Nicole Tabor Counseling | SimplePractice

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Administrative

Inquiry reason

Questions about therapy costs Insurance and coverage questions Ready to schedule my first appointment Check therapist availability for new clients Request a free consultation call Questions about treatment approaches or specialties Questions about availability or scheduling Other (please include below)

Referral source

If applicable, please enter how you found or were referred to our services

Billing & Payment

Payment method

How do you plan to pay?

Please note if I am not currently in network with your insurance, we will not yet be able to schedule an appointment unless you are planning to self-pay for sessions.

What insurance do you currently have? Please upload your insurance card if you wish to use insurance in the future below.

Regence/BCBS Providence Aetna Moda Other I am planning to self-pay/pay out of pocket

Insurance card upload

Upload a photo of your insurance card

Do you have secondary insurance?

Please select if you have primary and secondary insurance:

Yes, I have secondary insurance and will send this information to you to verify benefits No, I do not have a secondary insurance

Client Preferences

Preferred appointment times

Morning Afternoon Evening

Please note that I currently offer telehealth (virtual) only appointments and do not meet in person.

I understand

Please include your reason for inquiry or questions here. Thank you!

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.