Secure Contact Form

For individuals interested in participating in therapy groups at Quarternote Counseling

Please correct the errors described below.

Thank you for contacting Quarternote Counseling and your interest in participating in therapy groups at our practice.

Please be aware that groups require the participation of multiple individuals in order to take place. By submitting this form you are not obligated to participate in any group - this form is to express your interest only. When sufficient interest has been expressed by enough individuals to allow the group to take place, the days and times of the group will be determined and we will contact you to confirm whether or not you are still interested and/or available.

Please complete and submit this form. Your submission will be encrypted and secure. Fields with a red asterisk (*) are required.

**Please note: It is Quarternote's policy to send emails via Hushmail, and in an encrypted state, in order to protect your information. Upon receipt of our email, you will be required to establish and use a passphrase in order to open the email. We will send emails with encryption unless otherwise requested by you below. Please bear in mind that unencrypted electronic communication is allowed at your request, but is at risk for interception and could result in misuse of your personal information by unintended third parties. **

By clicking the box above you acknowledge and accept the risks involved with open, unencrypted email communication and that your personal information could be intercepted by unauthorized third parties.

Please provide a "code word" to be used in case a Quarternote staff member needs to verify your identity over the phone, or, if you would like to verify the individual calling is a Quarternote staff member. This code word should be easy for you to remember, and should not be shared with anybody. You may change your code word with us at any time.

You have the right to receive a “Good Faith Estimate” explaining how much your medical and 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 expected charges for medical services, including 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 health care 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
Quarternote Counseling will provide a Good Faith Estimate no greater than 3 business days after scheduling the first appointment.

Your information will be encrypted.