Forms and Documents

Potential Clients:

This form is what we use to consider if a client is a good match for our practice.

 

This form must be submitted and reviewed before your first appointment can be scheduled.

New Clients:
Informed Consent to Treatment

This document contains information specific to your provider and your care.  Your therapist will go over the information with you in person at your first appointment.

This document contains information about this practice that anyone seeking treatment here should be aware of. 

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. 

Good Faith Estimate

As of January 1st 2022

Under the law, health care providers need to give clients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.  

If you are a self pay or uninsured client, 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 our office manager for a Good Faith Estimate before you schedule a service, or at any time during treatment.  

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 this legislation and your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

Established Clients:

These forms empower your therapist to coordinate care with your other providers or to share confidential information with whomever you choose.