In-Office Sessions:
If you're a first-time client, please print, fill-out, sign and date all 7 PDF forms and bring them to your first session.
*Please note that even if you are not intending to pay by credit card, I ask that you fill out the credit card authorization. This authorization remains on file if you no-show for your scheduled appointment, do not give a 24 hour cancelation notice or if a session is conducted by phone or remotely.
Holding Your Scheduled Session Slot:
As a first-time client, you will be asked to make a payment, in advance, to hold your session slot. Please use the "Credit Card Preauthorization" form below. Please print, fill-out and sign and email back to me at [email protected] no later than 72 hours prior to your scheduled appointment. I will process the credit card payment once I receive the credit card information.
This payment will be applied to your first session. However, if you cancel or reschedule within 48 hours of your scheduled appointment, the payment will be reimbursed or applied to your next appointment. If a 48 hour notice has not been given to cancel or reschedule your scheduled session your payment will have paid for the session slot you are no longer attending.
As a courtesy, I will give you a reminder text to email your credit card information to hold your slot. However, if I have not received your information within 72 hours of your scheduled appointment and you have not contacted me to make other arrangements, your session will be automatically canceled.
Required forms:
1. Intake Form
2. Credit Card Preauthorization
4. Appointment Reminder Policy
5. Teletherapy Informed Consent
6. Disclosure Statement and Agreement for Services
7. HIPAA Notice of Privacy Practices
Remote Therapy Sessions:
If you are a first time client requesting therapy services remotely via Zoom, please download and fill out the 8 forms found above. Once completed, please scan all the forms and email back to me at [email protected] no later than 48 hours prior to your scheduled remote session. Please read the above information for holding your scheduled session slot.
Insurance Questionnaire:
I have included an Insurance Questionnaire to help you determine if reimbursements for psychotherapy services are available from your insurance company.
Right to a Good Faith Estimate:
Pursuant to the “No Surprises Act,” you have the right to receive a “Good Faith Estimate” explaining how much your mental health care is anticipated to cost. Under the law, your therapist must give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for psychotherapy services, if the patient requests such information. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.
You can ask your therapist for a Good Faith Estimate before you schedule a service. To request a Good Faith Estimate, please contact your therapist in writing at [email protected].
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 985-3059.
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