Insurance & Therapy Forms
I do not take insurance - but out of network benefits can be utilized. Reduced fee option for those with financial hardship and inadequate insurance.
I am a fee for service provider and considered an “out of network provider," with insurance companies. If you would like to utilize your insurance benefits to help cover the cost of treatment, I will provide a monthly itemized bill for services which you can submit (mail) to your insurance company for financial reimbursement. My statements include all of the info that the insurance company requires for you to be reimbursed. Your reimbursement amount is based on your particular policy, your deductibles, etc.
Call your insurance company to find out if you have out-of-network benefits.
Please check your insurance coverage carefully by asking the following questions:
- Do I have out-of-network mental health insurance benefits? (In-network benefits do not apply to my services).
- What is my deductible and has it been met?
- How many sessions per year does my health insurance cover?
- What is the reimbursement amount that will be paid to me for each session when I submit my claims?
x Sliding Scale / Reduced Fee Option:
I can offer a reduced fee under the following circumstances:
- You are experiencing financial hardship (and)
- You do not have out-of-network insurance benefits.
- Fee will be determined by a review of your circumstances.
Cash or check at time of service,Which means you will bring payment for each appointment. Once again, I will give you a statement at the end of each month which states you have paid in full for all of your appointments. You then submit (mail) to your insurance company for out-of-network reimbursement. I have no other involvement or connection with your insurance company, because I am not an in-network provider.
Cancellation Policy: Kindly give 24 hours notice.
Intake Form and Policies:
If you are a new client, please complete the following forms and bring them to your first therapy session, the intake form is completely confidential:
If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information: Authorization to Disclose Information Form