Disclosure Statement and Notice of Privacy Practices

These two forms together are a long read, but they have important information about my practice and your rights as a client.  I will need your signature of consent before starting treatment.

Intake Form

The Intake Form is a useful way to fill me in on important details of your life.  It provides me with a better sense of where you are coming from at the start of therapy.

My standard fee is $120 for a 50-minute session, and $170 for a 75-minute session.  As a Licensed Mental Health Counselor Associate I am unable to bill insurance as an in-network provider, but I can provide you with what you need to submit a claim to your insurance for potential out-of-network reimbursement.


I am available for sessions on Saturdays and Sundays, 8 AM to 8 PM.  On the left you will find PDFs of my Disclosure Statement and Notice of Privacy Practices, and my Intake Form.  Please read them and fill them out prior to our first session.  The Disclosure and Privacy Practices PDF is lengthy, but it contains important information about my practice and your rights as a client, and I will need to have your agreement and signature prior to starting treatment.  The Intake Form is a useful way to fill me in on important details of your life that can be valuable to treatment, but may not be otherwise addressed in our first session.  I also value it in the long term as an account of your life history told in your own writing.