Name: *

First Name

Last Name

Phone: *

(###)

###

####

How do you prefer to be contacted: *

Email

Phone Call

Out-Of-Network Provider *

I acknowledge that Cook Family Therapy, Inc operates as an out-of-network provider and does not bill insurance companies directly. If I wish to use my insurance benefits, I understand it is my responsibility to contact my insurance company to inquire about possible reimbursement. Cook Family Therapy, Inc can provide superbills upon request to assist with this process.

Yes

No

California Resident *

I understand that to receive services through Cook Family Therapy, Inc, I must be a resident of California.

Yes

No