FORMS & FEES
Scheduling and Fees
I currently provide appointments during weekdays and daytime hours only. My availability can fluctuate so please inquire about current openings and your needs. The initial expectation is to commit to a weekly session on the same day and time. Each session is 50 minutes.
I offer a free 15 minute phone consultation to discuss your needs and goals, answer any of your questions about the therapy process and to assess if we are a good fit. To schedule an appointment or consultation, please email me at firstname.lastname@example.org or call 512.649.8500.
- Individuals (13+): $150/session
- Couples: $175/session
Payment is due at the time of service and can be made with cash, check or credit card. *If client does not cancel within 24 hours of session they will be charged in FULL.
I do not currently accept any insurance. Upon request, I can provide you with documentation necessary to submit to your insurance provider for potential reimbursement.
Good Faith Estimate
Under the 2022 No Surprises Act, you have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.
Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.
- You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
- If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate and the bill.
For questions or more information about your right to a Good Faith Estimate, visit:
www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.
Please click the links below to download printable PDF files.
- Client Information
- Office Policies
- Notice of Privacy Practices
- Email and Texting Consent
- If needed, Consent to Treat Minors
Please do not send completed forms or any other confidential or sensitive information via e-mail, as it is not considered a secure form of communication and privacy cannot be guaranteed.