Client Forms

If you are new, please be sure to fill out the following forms, and bring them to your first session. This will help ease you in and allow as much time as possible to focus on you.

Client Intake Form

Insurance

I accept private pay as well as insurance supported payment.

I am happy to work with several different insurance carries and provide billing support as a courtesy for you. If you have insurance with mental health coverage, it is your responsibility to provide the appropriate billing information for your carrier. Additionally, please familiarize yourself with your insurance coverage related to out-patient mental health prior to services as coverage options vary significantly.

Any remaining deductibles and/or co-pays must be paid at the time of service as they apply to your plan.

To provide the easiest billing options for you, I also provide an elective automatic billing option that I would be happy to discuss with you.

I am currently a preferred provider for Blue Sheild Blue Cross and UBH/PBH.

Limits of Confidentiality

If you feel that you would like to collaborate your session with another provider, simply fill out the following form.

Authorization for Release of Information

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