Flower Mound Counseling Forms

Please print, read, complete, and sign these two forms prior to our first session:

• Informed Consent: Informed Consent Form 

• Intake Form: Intake Form

Additional Forms:

• Release of Information: Release of Information Consent Form

Good Faith Estimate Notice:

Under Section 2799B-6 of the Public Health Service Act, the “No Surprises Act,” you have a right to receive a “good faith estimate” explaining how much your therapy services will cost. Healthcare providers are required to provide clients who do not have insurance or who choose not to use their insurance for therapy services with an estimate of the cost of those services.

• You have the right to receive a Good Faith Estimate for the total cost of therapy services.

• Make sure your therapist gives you a Good Faith Estimate in writing at least 1 business day before your appointment. You may also ask your therapist for a Good Faith Estimate before you schedule an appointment.

• 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 of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call HHS at 1-800-958-3059.