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Name

First Name

Last Name

Email address

Phone number

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What would you like to work on?

Why are you seeking therapy services at this time?

Insurance *

I have Blue Cross Blue Shield PPO

I do not have Blue Cross Blue Shield PPO

When would be a good time for a 50 minute virtual/telehealth therapy session?

Monday–Friday, 9am-6pm start times

RATES: $180 per individual therapy session

Rates may vary if you have BCBS PPO insurance. All sessions are approximately 50 minutes long. Most major credit/debit cards accepted at the time of each session.

Address

1920 E Riverside Dr Suite A120 PMB 207
Austin, TX 78741-1342

Phone: 512-900-5805

Email: lane@upsidewellness.com