Initial Consultation Request

Emergency or Crisis Assistance

I don't provide emergency services. If you are experiencing a mental health crisis, please stop and call the National Crisis Line at 9-8-8 or if in immediate danger, call 9-1-1.

Client Information

First name

Last name

Email address

Phone number

Date of Birth

Looks like you have over 65. Do you have Medicare?

Option 1 Option 2

Is your Medicare policy with Kaiser?

Yes, with Kaiser Through another insurance company

Thanks for answering those questions. I ask because there are certain restrictions that licensed therapist run into when someone has Medicare. But since you don't have Medicare that will not be an issue. Please feel free to continue with the other questions below.

Since you are 65+ and have Medicare (other than with Kaiser), I unfortunately would not be able to work with you, even if you wanted to pay privately out of pocket. However, I can refer you to some wonderful Somatic Experiencing Practitioners (SEPs) and therapists who share my office with me. I recommend that you check out their websites and consider contacting them. If you do, confirm that their current status does still allow them to accept private pay arrangements with someone who has Medicare:

Suzanne Snijder van Wissenkerke, SEP | 909-239-8313 | suzannesvw.com
Rebecca White, LPC, SEP | ‭ 216-677-4907 | ‬ rebeccawhitecounseling.com

When are you available?

For our initial 20 min consult, when are you available? M-F 8:45am to 9:45am usually works for me but we can look at other times too.

If we move forward in working together, I offer sessions Monday through Thursday, 10:00am to 3:30pm. What is your availability like?

Initial Consult Preference

Zoom Consult (most common) Phone Consult

Ongoing Sessions Preference

In Person Sessions (most common) Zoom Sessions

Your Details

Payment Type

Private Pay - Out of Pocket Health Insurance Plan

Private Pay - Since we will not be involving insurance in our work together, our sessions can be more inclusive of things like personal growth goals or integration of spirituality in addition to any mental health concerns you have. I also extend a 15% "no hassle" discount off my regular fees. The 60-minute session fee with private pay is $170 and the 45-minute session fee with private pay is $128.

Primary Insurance Plan

HealthNet (in-network) Kaiser Permanente (in-network) Moda Health Plans (in-network) Pacificsource Health Plans (in-network) Pacificsource OHP (in-network) Trillium OHP (in-network) All Others (out of network benefits)

Do you have any other insurance policies?

Yes No I'm not sure, I need to check

Who is your other insurance policy with?

Good, please do double check and confirm any other insurance policies. It's super important that we figure that out so that billing can be done correctly. Getting this wrong creates huge problems.

Please talk to me about your goals and vision for our work together.

Insurance Billing - Using health insurance for psychotherapy is focused on something the insurance industry calls "medical necessity". The intention is specifically to address diagnosed mental health disorders, things like PTSD, unresolved stress and trauma, chronic depression, or chronic anxiety. There is also a focus on identifying and improving "functional impairments", which are the ways that one's mental health symptoms impact key areas of daily life such as capacity to work, study, sleep, take care of one's health, or get along with other people. We will talk more about this during our consult, but for now, please identify the key symptoms you think will be the primary focus of "medically necessary" services.

How do your mental health symptoms impact key areas of daily life such as capacity to work, study, sleep, take care of one's health, and get along with other people?

With the above symptoms and functional goals in mind, please talk to me about your aims for our work together.

Next Steps: After you submit this form, I'll review your information and get in touch soon, usually within a couple days, to schedule time for an initial Zoom or phone consultation. Before we schedule a consultation, I'll confirm that the likely one or two days/times I have available in fact work for your schedule. Thanks for your interest in working together!

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Initial Consultation Request

Emergency or Crisis Assistance

Client Information

When are you available?

Your Details

Emergency or Crisis Assistance

Christo Brehm, LPC, SEP

Inner Room Somatic Therapy LLC