Fees and Forms

New Client Forms - Please follow the instructions below
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 askdrgretchen@gmail.com 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 are saved to your computer. Once you have emailed the completed forms, you will receive an email from PandaDoc to sign the forms with your signature. 

Client Questionnaire
Contract for Services
Consent and Authorization Release (This form is not necessary to complete unless specifically requested)

Fees
The charge for a 50-minute session is $400.00.

Payment
I accept cash, Zelle transfers, checks, credit cards, and HSA/FSA cards.
Payment is due at the time of each session.

Insurance
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?

Cancellation Policy
Please provide 24 hours' notice if you need to cancel.

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (310) 625-6083.