Collaborative: Psychotherapy & Self-Discovery

Your info

First name

Last name

Phone

Date of birth

Reason for care

I do not offer standard, hour-long sessions. Please check below to indicate which type of session you are interested in.

Weekly or bi-weekly 2-3 hour sessions. A one-time intensive to address a single event.

Administrative

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

Once I have this form, I'll text you with a link to schedule your free, 20-minute phone consultation. We'll use that time to explore your goals, a brief history, and start to determine if this could be the right fit for you.

Billing & Payment

The services I offer are specialized and are not recognized by insurance carriers. I do not offer Superbills for Out of Network reimbursement.

Extended sessions & Intensives are billed at $225/hr. 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 I will not receive a Superbill for out-of-network reimbursement.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.