forms

FORMS

Please read, print out and sign the appropriate forms before your first appointment. Also, remember to bring these forms with you.

If you are unable to print these forms, they will be available at the office and can be filled out before your first appointment. Please be sure to arrive 15 minutes prior to complete all forms.

FORMS

Please read, print out and sign the appropriate forms before your first appointment. Also, remember to bring these forms with you.

If you are unable to print these forms, they will be available at the office and can be filled out before your first appointment. Please be sure to arrive 15 minutes prior to complete all forms.

INFORMED CONSENT FORM

• Confidentiality and Emergency Situations

• Cancellation and Coordination of Treatment

• Notice of Privacy Practices and Client Rights

• Consent For Treatment of Children or Adolescents

• Confidentiality and Emergency Situations

• Cancellation and Coordination of Treatment

• Notice of Privacy Practices and Client Rights

• Consent For Treatment of Children or Adolescents

CLIENT RIGHTS - HIPPA

FEES

Jennifer Farmer, LPC, is a fee-for-services provider and does not file your insurance for you. We will provide you with a “super bill” receipt, as it is called by most insurance companies, and will list the ICD-10 code for the services rendered that you may file with your insurance company.

Brainspotting

$150.00 / 1.25 hours

Therapy and Consulting Fees

$120.00 / 50 minutes

Court Ordered Evaluations

$250.00 / interview session plus report

Note: all services by appointment only

Acceptable Forms of Payment

Cash, check, credit card or HSA (health savings account)