Print one copy of:
Professional
Disclosure Statement,
Privacy Statement, and
Privacy
Statement Receipt.
Background
Information:
Print Adult Background for those 18 years and older;
Chilrens's Background Information for those under 18.
For
COUPLES, Please fill out one Adult form for each partner.
My Policies:
Print TWO copies --
one for you to read and keep,
and one to sign and give to me.
SO, you will KEEP for your own records:
Privacy Statement
Professional Disclosure Statement, and
Your copy of My Policies.
Please BRING IN TO YOUR FIRST APPOINTMENT, Signed and Completed:
Background Information,
My Copy of My Policies, and
Receipt of Privacy Statement.
Release of Information:
If you wish for me to give
information to or receive information from any other person who is not involved in your therapy
with me, you will need to provide me signed permission. In this case, please download this Release of Information,
fill it out and bring it to your next appointment with me.
FEES
50-Minute
Initial Consultation $150.00
*with
Non-Billing Discount 120.00
50-Minute Individual Session $125.00
*with Non-Billing Discount
100.00
50-Minute Couples/Family
Consultation
$150.00
*with
Non-Billing Discount 120.00
50-Minute Couples/Family
Session
$137.50
*with Non-Billing
Discount 110.00
* I extend a 20% Non-Billing
Discount for those who pay Out-of-Pocket at the time of service with
cash,
check, VISA, or Mastercard.
Temporary Discount Available
While
this posting appears, all new cash pay clients (cash, check or visa at time of service) will receive a 10% discount
from the above posted fees, when you mention this posting. This offer will continue for a short while to offset a shakey economy.
--Not available to insurance clients or those requiring billing.
INSURANCE
I am eligible to take a wide variety of insurance plans. With a couple of exceptions**
I require my full fee at the time of service, and you must bill your insurance for reimbursement of my services. I'm happy
to assist you in clarifying your insurance company's coverage for my services, and I will provide you all necessary information
for the filing of all necessary paperwork (such as a statement of services and charges, and/or signature on an insurance claims
form) in order for your claims to be paid.
**I am on the Providence/Pacificare (PBH) and United Behavioral Healthcare
(UBH) panels. Therefore, with these 3 insurances, I will take your copay at time of service, and I will bill your insurance
for payment of the claim. I will require copies of both sides of your insurance card, and all of the information listed on
my Background Information form completed. You will need to call your insurance company prior to your first appointment, and
obtain Authorization (complete with an Authorization Number which I will need for billing your insurance for the claim).
If you have any questions
or concerns, please do not hesitate to call or email me for clarification.
