Intake Paperwork

Save time before our first meeting.   Make it easier to meet with me remotely.  Download and fill out the forms below. Take a photo of the form(s) with your phone and email them back to me.

Working With Your Insurance Company

I am not an "in-network" provider for any insurance company. Depending upon your insurance carrier and coverage, PPO “out-of-network” reimbursement for sessions may be available. Your insurance plan may compensate you in full or in part for your visits to me, depending upon the provisions of your particular plan.

 

First, you will need to determine what your benefits are. You can find that information yourself, by calling the 1-800 number on the back of your insurance card. These questions will help determine if your insurance plan will compensate you for all or part of your expenses:

  1. Do I have "out of network" mental health insurance benefits?

  2. What is my annual deductible and has it been met?

  3. What month does the coverage end or begin?

 

You will be responsible for payment at the beginning of each session. I will provide you with a monthly summary of services (“Superbill”) that you can submit to your insurance company. You are responsible for all fees, whether or not insurance reimbursement is available.  I accept cash, check, or credit card payment.

 

Services provided may also be eligible for tax-free reimbursement under your employer-sponsored flexible spending account (FSA, MSA, or FLEX plan). Check with your company’s human resources manager for more information. In our experience, most HSA credit or debit cards have been accepted through our credit card payment, but this is not guaranteed.

Good Faith Estimate

You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. 

 

This estimate is not a contract and does not obligate you to obtain any services from the provider listed, nor does it include any services rendered to you that are not identified here.

 

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist.  You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

 

The fee for a 50-minute psychotherapy visit (in-person or via telehealth) is $160.00.

Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based upon a fee of $160 per visit, if you attend one psychotherapy visit per week, your estimated charge would be $640 for four visits provided over the course of one month; $1,280 for eight visits over two months; or $1,920 for 12 visits over three months.  If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment.

 

Calls between sessions, consultation, coordination of services, legal requests and/or reports are billed at the rate of individual sessions rate of $160 (to be billed on a prorated basis).  

 

You are encouraged to speak with me at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.

 

Superbills and/or receipt of services will always be provided to the client upon request at no additional fee. I provide superbills on a monthly basis. The client is responsible for managing their own out-of-network or health savings accounts benefits. 

 

Disclaimer: These estimates may change as the treatment progresses and are not a guarantee of treatment frequency, length or cost. Your signature does not require you to receive psychotherapy services from me.