Forms

Professional Disclosure Statement

Release of Information Consent Form

New Client Information Form

Perreard Professional Billing Insurance Form

Gender Dysphoria Questionnaire

Note: When completing electronic forms with multiline responses, please click or tab to the subsequent line to continue your statement so all of your text is visible on the PDF prior to submission. You may also need to click a second time to ensure your cursor is in the proper field prior to typing.

Rates

$210 per 55-minute session
$52.50 each additional 15 minutes per session or phone calls exceeding 15 minutes
$300 initial intake session (insurance clients only)
$100 no-show fee

Insurance

Services may be covered in full or in part by your health insurance or employee benefit plan. Please check your coverage carefully by asking the following questions:

• Do I have mental health insurance benefits?
• What is my deductible, and has it been met?
• How many sessions per year does my health insurance cover?
• What is the coverage amount per therapy session?
• Is approval required from my primary care physician?
• What is my out-of-network coverage?

I am in-network for the following insurance companies:

Reduced Fee

Reduced fee services are available on a limited basis.

Payment

Cash, check, and all major credit cards accepted for payment.

Cancellation Policy

If you do not show up for your scheduled therapy appointment and you have not notified me at least 24 hours in advance, you will be required to pay $95 for the missed appointment.