If you are new, please feel free to fill out these intake forms before our first session. These forms can also be filled out during the first session.
- Consent to Treatment Limits of Liability
- Consent for Minor
- Consent for Teletherapy
- Notice of Private Practice
Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your mental health care will cost.
Under the law, as a healthcare provider, Humano Family Counseling, Inc. must give clients who do not have insurance or who are not using insurance, an estimate of the expected charges for psychotherapy services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.
You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises..