Referral Form | Resonate Therapy

Resonate Therapy Client Referral Form

Please fill out this form in order for us to move forward in seeing if Resonate Therapy is a fit for your needs. Remember that we are only able to see clients who are residents of California.

Your information & answers to all of these questions are confidential and protected. Feel safe to answer freely and honestly!

What is your name?

Please provide the birthdate of the person seeking therapy:

A phone number to best communicate:

An email we can best reach you at:

What health insurance provider do you have? At Resonate Therapy, we are currently In-Network for Optum, United Healthcare, Anthem and UMR insurance plans.

**Please note that while Resonate may be in-network with these insurance plans, it is the client's responsibility to communicate with their provider about their individual insurance plan. Clients will be responsible fo any deductibles, copays or limits to coverage.**

Please select the following option that best suits your needs:

I can only pursue therapeutic services if I can use my insurance benefits in-network

I am open to learning about out-of-network insurance reimbursement options

I am looking to pay out of pocket for my therapy services

Please check your time of day preference for scheduling ongoing therapeutic services. Check all that apply, scheduling will still be coordinated directly with your therapist.

Mornings (8:00am-11:30am)

Afternoons (12:00pm-4:30pm)

Evenings (5:00pm-7:30pm)

Are you are interested in therapy for your child? If so, please list your child's name, age and a sentence or two about why you are seeking therapeutic services for them: If this box does not apply to you, please just write 'N/A'

Give us a few brief sentences on what brings you into therapy. Include anything else that you would like us to know.

Please list a few options for time frames that are good for a Resonate therapist to contact you for a 15 minute consultation call.

In your consultation call, a Resonate Therapist will inquire a little bit more about what's bringing you to therapy at this time. They will answer any questions that you have about fees, insurance, and the therapy process. This call is a great opportunity to see if Resonate Therapy will be a fit for your needs.

Thank you for taking the time to reach out to us. We are looking forward to connecting.