If you have any questions and would like to talk or set up a free 15 minute consultation, please don't hesitate to contact me!
Call (206) 858-0247 | Email firstname.lastname@example.org
Address: 4500 9th Ave NE Suite 300 #4 | Seattle, WA 98105
I charge $120 for 50 minute sessions and $190 for 80 minute sessions. I do not currently accept insurance but I can provide you with an invoice that you may submit to your insurance company for possible reimbursement. Please see the Fee Agreement for more information and details on payment policies, cancellations and financial hardship.
* Please notify me as soon as you know you must miss an appointment. You must cancel 24 hours prior to your appointment or you will be charged in full for the session, though exceptions may be made in cases of emergency or illness.
Please print, complete and bring the following forms to our first session.
- Disclosure Statement
- Notice of Privacy Practices
- Fee Agreement
- Client Intake Form
- Couples Intake Form
- Location & Parking Information
- Parking Map
Authorization for Release of Information Forms
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 dictates that your health care providers must obtain a signed release form in order to discuss your personal health information. Please have any relevant medical records forwarded to our office. Links to various providers and organizations' release forms are provided below.
- Polyclinic Group Health
- Seattle Children's Hospital
- Medical Center Swedish Medical Center (all campuses)
- University of Washington Medical Center & Clinics
- University of Washington Neighborhood Clinics
- Virginia Mason Medical
- Harborview Medical Center & Clinics
- Northwest Hospital and Medical Center & Clinics
- Valley Medical Center & Clinics
- Hall Health Primary Care Center
- General Release Form
- Request for Contact (for providers)