Please click on each link below to complete intake forms before our first session. Forms will be submitted to therapist electronically.

For Minors 
STANDARD NOTICE: “RIGHT TO RECEIVE A GOOD FAITH ESTIMATE OF EXPECTED CHARGES” UNDER THE NO SURPRISES ACT

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Note: Beginning January 1, 2022, the No Surprises Act (H.R. 133) will go into effect.
Most psychotherapy clients receive regular and recurring services. It may be difficult to estimate the total length of treatment to achieve initial goals. Additionally, client goals may change during treatment. With that in mind, a Good Faith Estimate may be provided for recurring services provided within a 12 month period (e.g. the cost of weekly sessions for a year). A new estimate can be provided for additional services beyond 12 months.