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Office Forms

Please download the biographical information form and the policy & consent form below. Please read and sign the policy and consent form before coming to the first session. There are two versions of the biographical information form. The standard form may be filled out by hand and brought to the first session. The e-mail version may be sent to me as an attachment. The release of information form only applies if there is another health care practitioner you would like me to talk to.

Policy & Consent

Biographical Information – Standard

Biographical Information -Email

Release of Information

KAP Consent Form

KAP pre-session guide

 

Good Faith Estimate(GFE) Disclosure

 

• Beginning January 1, 2022 it is legally required for all therapists and other health providers to provide all clients with a Good Faith Estimate (GFE). Below is NOT the actual Good Faith Estimate, but the disclosure of pertinent facts about the Good Faith Estimate. You will be provided your personalized Good Faith Estimate on an individual basis.
• I understand that the Good Faith Estimate (GFE) shows the costs of items and services that are reasonable expected for my healthcare needs for an item or service. The estimate is based on information known at the time the estimate was created and actual charges may differ.
• My standard session fees are determined based on a 50-minute unit.
• Extended Sessions: will be prorated based on the above rate.
• The Good Faith Estimate you receive can estimate the cost of therapy over the course of 13, 26, & 52 weeks.
• I understand that the Good Faith Estimate (GFE) does not include any unknown or unexpected costs that may arise during treatment. There may be an additional items or services requested separately. I could be charged more if complications or special circumstances arise. For example, extra sessions, phone conversations over 10 minutes in length, report writing. If this happens, federal law allows me to dispute the bill.
• I understand that if I am billed more than this Good Faith Estimate (GFE), I have the right to dispute the bill.
• I understand that I may contact the provider listed to let them know the bill charges are higher than the Good Faith Estimate (GFE).
• I understand I can ask them to update the bill to match the Good Faith Estimate (GFE), ask to negotiate the bill, or ask if there is financial assistance available.
• I understand that I may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If I choose to use the dispute resolution process, I must start the process within one hundred and twenty (120) calendar days of the date on the original bill.
• I understand that there is a $25 fee to use the dispute process. If the agency reviewing my dispute disagrees with me, I will have to pay the process on the Good Faith Estimate (GFE). If the agency disagrees with me and agrees with the provider, I will have to pay the higher rate.
• I understand I may go on the website to learn more information and get a form to start the process: www.cms.gov/nosuprises or call Health & Human Services (800)368-1019. 
• I understand if I have questions or for more information about my right to a Good Faith Estimate (GFE) or dispute the process I may visit: www.cms.gov/nosuprises or call Health & Human Services (800)368-1019.
• I understand that the Good Faith Estimate (GFE) is NOT A CONTRACT and does not require the uninsured or self-pay individual to obtain the items or services from any provider identified in the Good Faith Estimate (GFE). You are free to end therapy at any time and are not contracted for any number of sessions.
• However, I do have a 48 hour cancellation policy, so if you cannot attend a session and do not give 48 hours notice you will be responsible for payment of that missed session (but not for any subsequent scheduled sessions).