Client Superbill Request Form
This form is for clients of The Healing Collective. Once you have attended your session and paid for services,  please complete this form below. If you did not advise your clinician you would like to file for reimbursement, please do so via email. The Healing Collective does not apply diagnoses unless required for third party reasons. Your superbill will be uploaded into your portal and a notification will be sent within 7 days. In the form below, you will have the option to enter dates for services. Superbills can be generated for any amount of time ex: 4 sessions - 1 month; or sessions for calendar year. If you have any concerns or questions, please contact Liza at Liza@healingcollectiveteam.com .
Sign in to Google to save your progress. Learn more
Client Name *
Email Address *
Therapist providing services *
Date of service (one session)
MM
/
DD
/
YYYY
Date range of services (multiple sessions)
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Healing Collective. Report Abuse