Intake Forms

Intake Forms

Here is the paperwork you will need before we begin therapy:

IN PERSON THERAPY FORMS

Please print, fill out, and bring to your first appointment.

Individual Intake Form – one per person
Fee Agreement
Disclosure Statement
Notice of Privacy Practices

 

ONLINE THERAPY FORMS

Please print, fill out, and either scan/email to me or mail to

Jessa Zimmerman   1904 Third Ave, Suite 622   Seattle, WA 98101

Individual Intake Form – one per person
Online Therapy Fee Agreement
Online Therapy Disclosure Statement
Notice of Privacy Practices

Frequently Asked

Can I use insurance?
  • I do not take insurance directly.
  • Keep in mind that most insurance does not cover couples counseling (a “V code” diagnosis of relational distress).
  • If one of you has a medical diagnosis (anxiety or depression, for example) AND therapy is aimed at treating that condition and enhanced by working with the partner, insurance may cover the services. In that case, I can provide the receipt you would need for out of network reimbursement for our work together. Please ask me if you would like a receipt.
  • It is up to you to check with your insurance plan about possible reimbursement for out of network services.
  • If your company requests more information than is provided on the receipt, I will provide a brief summary of treatment and an explanation of why further treatment would be beneficial; I will not provide a treatment plan or therapy notes. You retain ultimate responsibility for payment for services if your insurance company decides that this documentation does not meet their requirements for coverage of your treatment.
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?
I accept checks, credit cards and cash in the exact amount due.
What is your cancellation policy?
If you miss a scheduled session with less than forty-eight hour notice or if you arrive at a couple’s session without your partner without prior arrangement, you will be charged for that session unless we can schedule that appointment within the same week. This does not include weekends.  Exceptions may be made, at my discretion, for emergencies. Appointment reminders are sent as a courtesy; it is still your duty to keep track of your appointments. Failure to receive a reminder is not grounds for not keeping an appointment.
How do we pay for online sessions?
Payment, via electronic invoice, must be completed 48 hours prior to the beginning of the online therapy session. In addition, full session fees apply despite any technical difficulties that may arise.

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