Secure Contact Form

Quarternote Counseling, LLC

Thank you for contacting Quarternote Counseling. If you are experiencing a psychiatric emergency and/or are at risk of harming yourself and/or others, please do not use this form. Instead, please call 911, visit your nearest emergency room, or contact the Suicide & Crisis Lifeline by calling or texting 988.

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.

I acknowledge that I have read and understand the statement above

Please check the box above before proceeding

Your full name (first and last)

Date of Birth

Your email address

**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. **

No, please do NOT use encrypted email communication with me at this time

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.

Phone number

Are we permitted to leave a voicemail message regarding scheduling?

Yes No

Code word

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.

Please indicate which group(s) you are interested in (please check all that apply)

Internal Family Systems Mindfulness/Meditation Group

Depending on interest level, this group will be offered online and/or in person

Dance/Movement Therapy Group for Chronic Pain/Anxiety/Depression

This group will be offered in-person only

Equine Assisted Psychotherapy Group

This group carries the possibility of having a group for adolescents and a group for adults depending on the level of interest. This group will be offered April to October 2023. This group carries the possibility of taking place on weekdays or weekends

On what day(s) might you be available for group? (Please check all that apply) NOTE: Groups will take place on the same day and at the same time for the entirety of the 8-week duration of the group.

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Available for Equine Assisted group only

Sundays

Available for Equine Assisted group only

What time of day is preferred? (Please check all that apply)

Mornings (8am-12pm)

Afternoons (12pm-5pm)

Evenings (5pm-7pm)

Please briefly describe the reason(s) for your interest in participating in a group and what issue(s) you would like to address in the group

NOTICE OF GOOD FAITH ESTIMATE
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 www.cms.gov/nosurprises.
Quarternote Counseling will provide a Good Faith Estimate no greater than 3 business days after scheduling the first appointment.

Your information will be encrypted.