- Professional Disclosure Statement
- Professional Disclosure Statement: Medicaid Clients
- New Client Info Form
- Insurance Information Form
- In-Network Insurance Use and Billing Agreement
- Out-of-Network Insurance Use and Billing Agreement
- Release of Confidentiality
- Professional Disclosure Statement for Non-Clients
- Gender Dysphoria Questionnaire
- Tele-Psychotherapy Consent Form
1) If desired, you may pay online via PayPal. Use the Pay Now button in the footer to complete your payment online.
2) Insurance billing for insurances with which I am in network:
- AllCare MedAdvantage and some other MedAdvantage plans*
- AllCare PEBB
- First Choice
- Health Comp
- OHP: Jackson Care Connect & AllCare
- Pacific Source
- Samaritan Choice
*Reach out to me for help assessing your MedAdvantage benefits
3) Superbills are prepared, upon request, for clients wishing to be reimbursed by insurances with which I am not contracted. Additionally, I am registered with Reimbursify for clients who wish to streamline submission of their superbills to their insurances (this does not apply to Medicare clients). Ask me about it or visit their website.
Fees are reviewed and established annually and are available upon request.
Sessions range from 45 to 90 minutes, depending on client needs, insurance billing restrictions, affordability, and the specific nature of work we are doing.
For more information, please feel free to call 541-482-3328 or email firstname.lastname@example.org. Please include in your correspondence with me what, if any, insurance you plan to use.