Intake Forms

Intake Forms

Here is the paperwork you will need before we begin therapy

THERAPY FORMS WITHOUT PRINTING:

Each of you should fill out the:

intake form

disclosure form/good faith estimate

**Make sure to confirm your email address. Check your inbox/spam folder for the email from Adobe.**

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.

IMPORTANT: CLIENTS 64 AND OLDER

If you or your partner are or will be 65 years old in the next year, please sign this private pay contract because I have opted out of Medicare.

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?
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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