New Client Forms
Please use the button below to download your fillable patient intake form. You will need to save it to your computer, enter your details, then email the file to firstname.lastname@example.org with your full name in the subject line. Do not enter your details in the webpage as they will not save. Make sure the document is saved to your computer. You can sign with an e-signature if you have Adobe, or you can scan the document to send back to us.
The charge for a 50-minute session is $300.00.
I accept cash, Zelle transfers, checks, credit cards, and HSA/FSA cards.
Payment is due at the time of each session.
I am not "in network" or "on panel" for any insurance plans. If you have PPO insurance, your health insurance should include coverage for mental health care (outpatient, out-of-network psychotherapy). I will provide a SuperBill approximately monthly. You may submit the SuperBill directly to your insurance company for full or partial reimbursement. Please check your insurance carefully by asking the following questions:
- What is my deductible? How much of it has been met?
- Is there a limit to the number of sessions covered? If so, what is it?
- What is the coverage/reimbursement for services provided by a psychologist?
Please provide 24 hours' notice if you need to cancel.