Through The Looking Glass
Psychoanalytic Therapy, LLC
Insurance Coverage
Patient Name: _____________________________
Date: _______________________
Student
Non-student
I do not have insurance.
I am not using my insurance to cover my fees.
I have Medicaid insurance and will not use it to cover my fees. I have been advised that I
could use this bene t at another facility for no cost, but have waived this right.
I am using my primary insurance (i.e., I have no other health or mental health insurance) to
cover my fees
I am using my secondary insurance (i.e., I have other health or mental health insurance even if through a partner or parent) to cover my fees.
Insurance Information:
Name of Company: _______________________________________
Group #: _______________________
Individual ID #: ______________________
I have discussed my Insurance Coverage with Valerie Levy, LCSW, and hereby agree to cover
fees not paid by my insurance company.
I hereby assert that I, _____________________, will not cause physical harm to myself.
In the event that I feel I may injure myself, then I will go immediately to the nearest emergency
room.
Patient Signature:
Witness:
____________________________________
__________________________
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Through The Looking Glass Psychoanalytic Therapy, LLC | 110 E. 71st St. New York, NY 10021
Tel: 646-741-9608