In Goodyear, N Scottsdale, Surprise, N Phoenix/Anthem, & Prescott
Main number: (480) 500-8869
Online Forms Portal
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***OPTIONAL**** Use Downloadable Forms to Get Started
Download & Bring Completed/Signed Forms to Your First Appointment
All adult clients (over 18), please complete the first 5 forms.
Couples and Families, in addition to the first 5 forms, please complete the "FOR FAMILIES & COUPLES ONLY" form.
For minor clients (under 18), parents complete the first 3 forms and the "FOR MINORS ONLY" Form (parents sign).
For clients planning to meet by Telehealth (Video), fill out the applicable forms above and the "Telehealth Informed Consent" form below
(Additionally, for clients of therapists under Supervision - complete the Consent for Supervision form below)
HIPAA Privacy Information is provided for your information and does not need to be printed.
If you have any questions please call or text 480-500-8869.
Good Faith Estimate
No Surprises Act 2022
You have the right to receive a “Good Faith Estimate” explaining how much your medical/mental health care will cost under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item.
You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.