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Forms & Fees

Forms


If you are a new client, please complete the following forms and bring them to our first session.
If you plan to use insurance, please bring your insurance card.

 

Self Assessment

Client Information Sheet

Office Policies & Informed Consent

 

Fees 


Rates: $180 per 45-minute session and $200 per 1-hour session. The initial intake session (75 minutes) is $250. 

 

My services may be covered in whole or in part by your healthcare insurance plan.  If you have questions about your plan, please feel free to contact my billing service: Holly Kelly Billing, 503-446-9942; hollybilling@gmail.com I am on the panel of Regence Blue Cross Blue Shield of Oregon, ODS Health Plan, Pacific Source, Lifewise Insurance, and Lyra Health. Insurance plans may offer “out-of-network” mental health benefits and I accept coverage as an out of network provider. You can learn more about this by contacting your insurance plan or by having my billing service look into this for you. On a limited basis, and upon request from a client who demonstrates financial hardship, the fee for therapy may be adjusted. 


Payment and/or copayment is due at time of service unless other arrangements have been made with me in advance. I accept checks, cash, and cards. Major credit cards may be used for outstanding balances or as payment for your insurance deductible.