Heart Centered Psychotherapy, Portland OR, Wellness Counseling
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Forms and Fees

Links to my Documents for New Clients:
PLEASE--scroll down below these links & carefully read the printing instructions provided below.

HIPAA Client Rights Information

Adult Background Information

Children's Background Information

Professional Disclosure Statement

My Policies

Privacy Statement

Privacy, Policies, & PDS Receipt

Release of Information

Print one copy of:
2013 HIPAA Client Rights Information,
Professional Disclosure Statement,
My Policies, 
Privacy Statement, and
Privacy Statement Receipt.

Background Information:
Print Adult Background for those 18 years and older;
Chilrens's Background Information for those under 18. 
For COUPLES, Please fill out one Adult form for each partner. 

SO, you will READ & KEEP for your own records:
2013 HIPAA Client Rights Information,
Privacy Statement,
Professional Disclosure Statement, and
My Policies.

Please BRING IN TO YOUR FIRST APPOINTMENT, Signed and Completed:
Background Information with a copy of your insurance card, &
Receipt of Privacy Statement. (Couples: you may both sign one Receipt)
Release of Information:
IF you wish for me to give information to or receive information from any other person who is not involved in your therapy with me, you will need to provide me signed permission. In this case, please download this Release of Information, fill it out and bring it to your next appointment with me.

If you have any questions or concerns about my paperwork, please email or call me. 

50-Minute Individual Session         $130.00 
     *with Non-Billing Discount         100.00
50-Minute Couples Session      $160.00
     *with Non-Billing Discount         130.00 

* I extend a $30 Non-Billing Discount for those who pay Out-of-Pocket at the time of service with
   cash, check, credit/debit card, Square Cash, or FSA/HSA card.

I am eligible to take a wide variety of insurance plans.  With a couple of exceptions** I require my full fee at the time of service, and you must bill your insurance for reimbursement of my services. I'm happy to assist you in clarifying your insurance company's coverage for my services, and I will provide you all necessary information for the filing of all necessary paperwork (such as a statement of services and charges, and/or signature on an insurance claims form) in order for your claims to be paid.
**I am on these Insurance Panels:  Providence/PacifiCare (PBH);  United Behavioral HealthCare (UBH); Blue Cross/Blue Shield; Regence; Anthem; PacificSource. 
With these specific insurances, I will take your copayment at time of service, and I will bill your insurance for payment of the claim.
I require copies of both sides of your insurance card, and all of the information listed on my Background Information form completed.
You will need to call your insurance company prior to your first appointment, and obtain Authorization (complete with an Authorization Number which I will need for billing your insurance for the claim).
If you have any questions or concerns, please do not hesitate to call or email me for clarification. 

~~ If you need more information, please don't hesitate to contact me by phone or e-mail ~~