Romi Cumes Somatic Therapy, P.C.

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

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State

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Administrative

Inquiry reason

Seeking in-network psychotherapy (Anthem Blue Cross PPO member) Seeking psychotherapy (private pay or out-of-network) Ready to schedule my first appointment and open to the first available provider Open to a waitlist if needed Review treatment approaches, fees, or insurance information (This information can be found at: https://romicumes.com/therapy/ )

Referral source

How did you find out about us? (Referral, Google or website, Therapy Finder, Welltrack, Psychology Today, etc.)

I understand that provider availability varies and that a waitlist may be required.

Billing & Payment

Insurance details

I have Anthem Blue Cross PPO insurance (eligibility and benefits vary) I do not have Anthem Blue Cross insurance (superbills available upon request)

Client Preferences

Preferred clinician

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Preferred modality

Is there anything that the practitioner needs to know?

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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.