Patient Information

Services Fee Schedule

Services rendered as self-pay can be accepted as cash, personal check, or credit card due at the time of the appointment. Insurance products we currently use are Premera, United Health or First Choice and specific Military policies. We must establish insurance eligibility before having an initial appointment.

Services Fee schedule
CodeDescriptionCharge
90792 Psychiatric Diagnostic Evaluation - 90 minutes $300.00
99205 Psychiatric Diagnostic Evaluation w/ Medication Evaluation - 90 minutes $375.00
90833/
99214
Individual Therapy w/ Medication management - 60 Minutes $180.00
90834 Individual Therapy w/ Medication Management w/ Client or Family - 60 minutes $235.00
90880 Hypnotherapy - 60 minutes $150.00
90880/
99214
Hypnotherapy with Medication management - 90 minutes $180.00
90853Group Therapy Session - 90 minutes$125.00
90853/
99213
Group Therapy Session w/ Ketamine - 180 minutes $350.00
99213 Office/Outpatient Visit, Simple (Established Clients) - 20 minutes $100.00
99214 Office/Outpatient Visit, Medication Management (Established Clients) - 30 minutes $125.00
99215 Office/Outpatient Visit, Complex (Established Clients) - 60 minutes $250.00
99441 Phone/Text/Email visit (other than scheduling or brief chats) $50.00
No Code Ketamine Assisted Therapy - 180 minutes $860.00
No Code Ketamine Assisted Therapy Package - 3 Sessions $2460.00
No Code Late Appointment Cancellation (less than 24 hours notice)
- 1st Late cancellation
- 2nd Late cancellation
- 3rd+ late cancellation
$0.00
$15.00
$25.00
No Code "No Show" (missed appointment without cancellation)
- 1st no show
- 2nd no show
-3rd+ no show (up to half of session fee charge but no less than $75)
$25.00
$50.00
$75.00
No Code Official Paperwork Request (Evaluation Letters, FMLA, etc.) $100.00

Patient Forms

Please print, fill out, and bring or send these forms to your first patient visit. If information has changed, please repeat this process.

  • Sliding Scale Finances Infographic
    An artistic rendering of the "green bottle" approach to determining where you fall on a sliding scale for finances.

    If you have a full green bottle, please pay 100% of the fees for service, if you have a ¾ full green bottle, please pay 80% of the fees for service, if you have ½ full green bottle, please pay 60% and if your green bottle is ¼ full, please pay 40% of the service fees.

    This scale can be applied to the service fees for a fully established person for follow up work and not to the initial evaluation service fees.

  • History and Background Information
    History and background information on the patient.
  • Release of Information
    Permission to access medical information from a previous provider.
  • Generalized Anxiety Disorder 7-item Scale (GAD-7)
    A questionnaire with seven items, which helps the patient to rate levels of anxiety felt over the past two weeks.
  • Patient Health Questionnaire (PHQ-9)
    A questionnaire with nine items, which helps the patient to rate levels of depression felt over the past two weeks.
  • Mood Calendar
    A printable calendar to track moods and symptoms.