Forms

If you are a new client, please complete the following forms and bring them to our first session.
If you plan to use insurance, please bring your insurance card.

 

Self Assessment

Client Information Sheet

Office Policies & Informed Consent

 

Fees 

Rates: $180 per 45-minute session and $200 per 1-hour session. The initial intake session (75 minutes) is $250. 

 

My services may be covered in whole or in part by your healthcare insurance plan. I am on the panel of Regence Blue Cross Blue Shield of Oregon, PacificSource Health Plans, and I am a Medicare provider. I may accept coverage as an “out-of-network provider” for other insurance plans.

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Payment and/or copayment is due at the time of service unless other arrangements have been made with me in advance. I accept checks, cash, and cards. Major credit cards may be used for outstanding balances or as payment for your insurance deductible.

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Please be aware that managed health care plans often require authorization before providing reimbursement for mental health services. In addition, most insurance companies require at least a clinical diagnosis; sometimes additional clinical information such as treatment plans or summaries may be required for payment of services.  Even if you have insurance, payment of services ultimately is your responsibility if coverage is denied.

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Services via Technology 

 

If you choose to contact me and/or participate in therapy services via telephone, email, text or other on-line platforms such as Doxy.me, you acknowledge that there are potential risks to confidentiality of information. I will make reasonable efforts to use secure communication.
 

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Billing

 

I use a mental health billing service to handle and track your account. That service will be provided information for the purpose of billing and collections unless otherwise requested by you. You may make payment using checks, cash, or major credit cards. Major credit cards may be used for outstanding balances or as payment for your insurance deductible.