Forms & Fees
Please complete the forms below, every person must complete the first two forms. Before your first visit, send completed forms to email@example.com. Your insurance will be verified and you will be notified via email regarding your behavioral health benefits deductible and co-payment.
- New Patient
- Patient Service Contract
- Payment Authorization
- Child Intake
- Two Way Release
- Partner Diagnostic Questionnaire
For clients with mental or behavioral health insurance coverage; prior authorization may be required. Usually, a co-payment is due at the time of service, normally between $10 and $35 per visit after the deductible is met. I'm contracted with several insurance companies including Aetna, Anthem, Cigna, Blue Cross, Blue Shield, Horizon Health, Magellan, MHN, Optum, and Tricare, Triwest, Value Options, United Health Care, UBH, UPMC, and a few others.
For private-paying clients, the fee per session is $150. Clients with financial hardship can discuss temporary accommodations prior to the initial consultation.
EAP: Employee Assistance Programs are offered by some employers allowing for 3-8 sessions at no charge to the client. After that, payments may be charged through mental/behavioral health benefits.
Payment options: Cash , check ,credit card( ), or PayPal.