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Please print and complete the appropriate paperwork below. Bring to the initial session to get started.

Initial Paperwork: Please bring a completed version of these two forms. If you would like to discuss them or have any questions please let me know.

Additional Paperwork as Needed:

Good Faith Estimate Notice

You have the right to receive a “Good Faith Estimate” explaining how much your

medical and mental health care will cost.

Under the law, health care providers need to give patients who don’t have

insurance or who are not using insurance an estimate of the expected charges for

medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of

any non-emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a

Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you

can dispute the bill. Make sure to save a copy or picture of your Good Faith


For questions or more information about your right to a Good Faith Estimate,


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