Please note that making an initial contact with the practice does not necessarily begin a therapy/counseling relationship with this office. Therapy/counseling begins after the initial evaluation in our office and the new patient forms packet is completed and accepted by our office. At that time, you and the therapist will both evaluate this information and assess whether or not we are the appropriate provider for your therapy/counseling needs and if you want to work with our office going forward.
Below is a link to our HIPAA approved forms site, IntakeQ. On this site you will find all of our needed new patient/client forms, as well as a returning client form (if you are returning to therapy less than one (1) year since your last appointment), in electronic versions. You will also have access to forms such as: our Release of information form, the Informed Consent form for therapeutic treatment of an adolescent and a non-subpoena contract for clients in couple, family, or child/parent therapy.
We ask that you read, review and sign these forms in order to schedule an initial appointment with our practice.
Click the button below to access the following forms:
Please email us at firstname.lastname@example.org, or call 703-518-8883 to discuss your wanted care and clinical needs. At that times, we will give you the password for the above forms.
Fees – We believe in Transparency
The practice does not participate as an in-network provider with any insurance company plans. Given that therapeutic services are reimbursable, depending on your insurance coverage, we encourage you to contact your insurance company directly to help inform your decision about therapy.
The practice does provide clients with a detailed statement of receipt that can be submitted to all insurance companies, if your plan includes and reimburses you for out-of- network mental health benefits.
We suggest that all clients wanting to use their insurance benefits, contact their insurance companies about what their benefits are to make informed decisions. When asking about reimbursement for services provided by our practice, we suggest you ask what your “out-of-network mental health benefit” is, so that you can make an informed decision about care with our office. Some questions you may want to ask your insurance company to inform your decision are:
- What is my out-of-network mental health benefit?
- Do I need to meet a deductible to receive reimbursement for out-of-network mental health coverage?
- Does my insurance company provide a mental health claim form?
Good Faith Estimate
In compliance with the No Surprises Act effective January 1, 2022, all healthcare providers are required to notify clients of their federal rights and protections against “surprise billing.”
The No Surprises Act requires that we inform you orally and in writing of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, whether or not a client is uninsured or if a client elects not to use their insurance.
Brickel and Associates does not participate with any insurance plans, therefore, we are out-of-network providers.
Additionally, we are required to provide you with a Good Faith Estimate (GFE) of the cost of services. You will receive a formal GFE of costs for services when an appointment is scheduled.
As you may already know, it is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, the GFE you will receive will include a fee schedule for the services typically offered by our practice and your therapist, and as always, we will collaborate with you on a regular basis to determine how many sessions you may need.
It is a federal requirement that we have each client sign this form to begin/resume treatment. Your therapist will complete the diagnosis code and their information for your care, sign it and return a final copy to you to keep for your records. We encourage you to save a copy or picture of your completed Good Faith Estimate (GFE) for your records.
You are always welcome to ask your healthcare provider for a Good Faith Estimate (GFE) before you schedule an item or service.
Per the No Surprises Act , if you receive a bill for services, that is at least $400 more than your Good Faith Estimate (GFE), you can dispute the bill.
For questions or more information about your right to a Good Faith Estimate and this federal requirement, visit www.cms.gov/nosurprises.
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