Intake Forms


Information about Fees

    Initial Assessment fee $165
    38-52 minute fee for Individual or Couples Psychotherapy $140
    51-60 minute fee for Individual or Couples Psychotherapy $160

    If you are a member of a HMO/PPO, payment to your provider may be discounted from that stated above. It is important to be aware of your plan deductible and your co-pay responsibility. The expectation is that co-pays (or full fees for self pay clients) are paid on a per session basis to your treating psychotherapist. Cash or check are accepted forms of payment.

    I understand that I am responsible for any deductibles, co-insurances, or amounts for services not covered by the insurance carrier, including full session charges for missed appointments and those cancelled less than 24 hours in advance.

    I am aware that if I choose to use a credit card to make payment for my copay, deductible, statement balance or late fee, there is an additional $3.00 charge per transaction, for processing.

    I hereby authorize Brill Counseling to release such information as may be requested by my insurance company for purposes of billing or coverage clarification. Further, I hereby authorize any insurance coverage providing benefits or payments for psychological/mental health services received to be assigned to Brill Counseling. I also permit a photocopy or other facsimile of this authorization to be used in place of the original assignment.

    Signature