Fees & Form

Forms

Adult Intake

Youth Intake

Professional Disclosure/Informed Consent

Release of Info

Telehealth Agreement

HIPAA

CreditCard Auth.

Financial Time of Service

Walk & Talk

Good Faith Letter

Forms may be downloaded or printed off, and completed forms may be sent to [email protected].

Fees

Cost (per session) $100 - $175
Sliding Scale: Ask about availability

Insurance Accepted:

• Kaiser
• CIGNA
• MHN
• MODA
• Pacific Source
• Regence (Optum, BC, BCBS, Anthem)
• First Choice Health
• Aetna
• PBH/UBH
• Magellan
• Various EAP Services

Accepted Payment Methods:
Cash, Check, Debit, Discover, Health Savings Account, MasterCard, Visa, American Express