Client Forms
If you are new, please feel free to fill out these intake forms before our first session. These forms can also be filled out during the first session.
- Adverse Childhood Experience Questionnaire
- Adult Intake Packet
- Child Intake Packet
- Limits-of-Confidentiality
If you feel that you would like to collaborate your session with another provider, simply fill out the following form.
No Surprises Act
This act was passed to help prevent surprise billing in emergency rooms and other inpatient hospital settings. However, this does apply to all providers including myself. This new act applies to anyone who is not using or does not have in-network benefits from their insurance to receive services from my practice. What this means it that you have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.
It is already a standard part of my practice for any clients who start treatment with me to receive and sign a document that shows my billing polices and fees for sessions, missed appointments, etc. I also verbally review this with clients and hold space to answer any questions that they may have to ensure they understand this information. I have also included information about fees and insurance on my website under the financial information section.
I’ve included a document, No Surprise Act that gives a little more about it or you can go to https://www.cms.gov/nosurprises https://www.cms.gov/nosurprises to learn more as well. Please reach out to me if you have any questions.