Jacob's Well Counseling Center, LLC

Billing options

We accept several payment options, including insurance, cash payments, out-of-network benefits, and scholarships from local churches. Our administrative team is happy to help you explore what works best for you.

Insurance Options

We work with numerous major insurance providers in order to make counseling as financially accessible as possible. Listed below are just some of the providers we partner with. To verify your benefits please fill out the form below.

Understanding Your Benefits

We make it easy to understand and use your insurance benefits for mental health care.

Coverage Verification

We verify your benefits before your first appointment

Transparent Pricing

Clear information about copays and deductibles

Direct Billing

We handle insurance claims, denials and billing for you

Easy Process

Simple steps to get the care you need

Getting started!

Once you are scheduled with a counselor we will contact you about your benefits and payment options. Please fill out this form so that we can best support you in this process.

Submit your insurance information

We connect you with a counselor

Select your preferred payment option

Full Name *

Date of Birth *

Email Address *

Phone Number *

Insurance Provider *

Member ID *

Group Number

Policy Holder Name

Relationship to Policy Holder

Preferred Appointment Time

Insurance Card (Front) *

Insurance Card (Back) *

Additional Information

Protecting Your Privacy

This form is intended to collect insurance information to assist with verifying coverage and eligibility. Please do not include any personal health information (PHI) beyond what is requested.

We are committed to protecting your privacy in accordance with the Health Insurance Portability and Accountability Act (HIPAA). All information submitted through this form is transmitted securely and will be used solely for the purposes of insurance verification and related administrative functions.

Submission of this form does not establish a provider-patient relationship. If you have urgent medical concerns, please contact your healthcare provider directly.

I acknowledge and agree to the privacy practices described above. *

Important Information

What to Bring

•Current insurance card
•Valid photo ID
•List of current medications
•Any relevant medical records

Payment Options

•Insurance copayments
•Credit and debit cards
•Cash and check payments
•Flexible payment plans available

Questions About Your Coverage?

Our administrative team is here to help you understand your benefits and make the most of your insurance coverage.

Call Us Today Contact Us