Forms


Before our first session, I will request that you download, print and read/complete the three forms to the right. Please bring these forms to our first session. If you have any questions about the forms, I’m glad to assist you in any way I can. We can address those questions when we meet.

Disclosure Statement
Intake Form
Notice of Privacy Practices

When I need to consult with other professionals (such as a physician or attorney) about our work together, I will ask you to download, print and read/complete the Release of Information form .  This form gives me your written consent to share information about our work together with specific persons whom you designate.

Release of Information

Fees / Insurance


 Fees

My fee is $205 per 45-minute session for work with individuals.  Payment is due at the beginning of each session.  

If you can’t afford my full fee, I have a limited number of reduced fee slots.  Please feel free to ask about the availability of these appointments.

Insurance

I am an out-of-network provider on all insurance plans.  My services may be covered in full or in part by your health insurance or employee benefit plan, but I cannot guarantee coverage.  Once we decide to work together, our financial agreement is between you and me, not between me and your insurance company.  If you’d like to use insurance to cover your work with me, please check your coverage carefully by asking the following questions:

  • Do I have mental health benefits?

  • Do I have out-of-network mental health benefits?

  • What is the rate at which out-of-network services are covered?