Intake Forms
Intake Forms
Here is the paperwork you will need before we begin therapy
THERAPY FORMS WITHOUT PRINTING:
This version of the individual intake form can be filled out online, saved to your computer, and then emailed to me. You and your partner each need to fill out and send this form.
Email me you and your partner’s full name and email address, and I will send an electronic version of the disclosure statement for e-signature.
THERAPY FORMS TO PRINT AND EMAIL:
If you prefer, please print, fill out, and email to me before your first appointment.
Individual Intake Form – one per person
Fee Agreement and Good Faith Estimate of Charges
Disclosure Statement
And for your information:
Notice of Privacy Practices
Frequently Asked
Can I use insurance?
- I am a cash only practice. I do not work with any insurance as an out of network or in network provider. If you require a statement of proof of services, I can provide one for you. I do not provide additional information to insurance companies such as W-9s, complete out of network provider approval forms, or provide clinical reviews or superbills.
Do you offer reduced fees?
FINANCIAL HARDSHIP SPACES AVAILABLE UNAVAILABLE AT THIS TIME:
- I maintain a limited number of appointments at a reduced rate for clients who meet the criteria for financial hardship.
- If your household has an income less than $45,000 per year (adjusted upwards by $5000 per year per child in the household) AND you do not have insurance coverage that would reimburse you for counseling services, you may request the financial hardship rate ($90 for 50 minutes and $145 for 80 minutes).
- These slots are given on a first come, first served basis and must be arranged in advance.
- In order to serve the most clients possible, if you miss two appointments without prior arrangement, your financial hardship slot can be forfeited and given to someone else.
What forms of payment do you take?
What is your cancellation policy?
How do we pay for online sessions?
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