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 allowing us to provide you services. Please complete and submit this form. Your submission will be encrypted and secure. Fields with a red asterisk (*) are required.

NOTICE TO ALL POTENTIAL NEW CLIENTS: Quarternote Counseling is currently accepting new clients. Availability and wait times vary and may be anywhere between 2 weeks to 3 months depending upon the decision of the Clinical Director concerning which Quarternote therapist possesses the training and experience that appears to be best suited for the individual seeking services. We will contact individuals who have submitted this form when an appointment on that therapist's schedule becomes available and in the order in which the contact forms were received. However, we also strongly encourage you to seek services elsewhere during this time if needed. If, after 3 months, you are still in need of and/or interested in receiving services at Quarternote Counseling and have not received a call from us please contact our office at 571-602-0743.

PLEASE NOTE: We will contact you via email and/or telephone and leave a voicemail message (when permitted) making you aware of our appointment availability. If you have given permission for us to leave a voicemail message, we will do so. Please be aware that Quarternote does not "hold" appointments for those on the waitlist who have been contacted to schedule their first session. We will continue to contact others on the waitlist who are seeking services. If you no longer wish to receive services from Quarternote Counseling and should be removed from our waitlist please contact Practice Manager Becky Noonan at 571-602-0743 with this information.

Thank you.

I acknowledge that I have read and understand the statement above

Please check the box above before proceeding

CLIENT INFORMATION

Your full name (first and last)

Will you be the client or are you contacting us on behalf of somebody else?

I will be the client I am contacting you on behalf of somebody else

Client's name

Client's Date of Birth

Please tell us your relationship to the client

What are the client's pronouns?

EMAIL AND PHONE COMMUNICATIONS:

Your email address

**Please note: It is Quarternote's policy to send emails via Hushmail, with encryption in place, in order to protect your information. Upon receipt of our email, you will be instructed to sign in using a Google, Microsoft or Apple email account, or create your own Hushmail-specific password, in order to open the email. We will send emails with encryption unless otherwise requested by you below. Please be aware 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. **

Do you want email communications to be encrypted? Please select how you would like to receive email communications from our office. You will be asked to confirm these permissions at the time of your first appointment.

YES. Please use encryption when sending me emails in order to protect my personal information NO. Please do NOT use encryption when sending me emails. I am aware of and accept the risk of my personal information being intercepted by unintended third parties.

Phone number

Are we permitted to leave a voicemail message regarding scheduling?

Yes No

May we send you a text message on this number related to scheduling? Please note that electronic communications may be intercepted by unauthorized third parties and if you choose to receive text messages you do so understanding and acknowledging this risk.

Yes No N/A (this phone number is not a cell phone)

Messaging Terms & Conditions:

You agree to receive informational messages (appointment reminders, account notifications, etc.) from Quarternote Counseling. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at admin@quarternote.hush.com. You can opt out at any time by replying STOP.

‍Mobile SMS Messaging Privacy Policy:

Information collected:
We may collect information, such as name, phone number, and email address.

Use of information collected:
We may use the information we collect to perform the services requested including billing, customer service, appointment reminders and other administrative requests.

Sharing of information collected:
We may share information we collect with payment processors, legal authorities, partners so that these service providers can perform their normal duties. We do not share, sell, rent, or trade any information provided with third parties for promotional purposes.

As a current or prospective customer, you understand that you can text us STOP at any time to opt out of receiving SMS text messages from us. You can text us HELP at any time to receive help.

You understand that the messaging frequency may vary. Messaging & data rates may apply.

‍Your mobile information will not be shared with any third parties/affiliates for marketing/promotional purposes. All policies are followed as per CTIA guidelines 5.2.1. At any time if you want your information to be removed, you can contact us via our email address or regular mail.

How would you like to be contacted concerning appointment availability?

Please contact me via email using the preferences as indicated above Please contact me via telephone using the preferences as indicated above Please use both email and telephone to contact me using the respective preferences as indicated above

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.

Hint for code word

Because some may have difficulty remembering their code word, Quarternote asks clients to establish a code word hint, so we may provide this hint in the event of you not remembering your code word. The hint may be anything you feel will help you recall the code word you have on file with our practice. Like the code word itself, the hint may be changed at any time.

Will health insurance be used for the therapy services?

Yes No

Do you carry more than one health insurance policy?

Yes No

PRIMARY INSURANCE INFORMATION

What is your PRIMARY insurance? If your primary insurance company is not listed please select "Other/Not Listed" and provide the name in the space provided.

Anthem BCBS

CareFirst BCBS

United Healthcare

Anthem HealthKeepers Plus (a Medicaid plan)

Molina Complete Care of Virginia (a Medicaid plan)

United Healthcare Community Care (a Medicaid plan)

Sentara Community Plans (a Medicaid plan)

Other/Not Listed

If you selected "Other/Not Listed" above, please provide the name of your PRIMARY insurance here

Client's name as it appears on the PRIMARY insurance card

Member ID number as it appears on the PRIMARY insurance card

Please enter the number as it appears on the insurance card, including all letters and numbers

Is the client the policyholder of this PRIMARY policy?

Yes No

PRIMARY policyholder's full name (first and last)

PRIMARY policyholder's relationship to the client

PRIMARY policyholder's Date of Birth

"Member Services" or "Provider Services" phone number on the PRIMARY insurance card

This is usually located on the back of the insurance card

Out of Network (Non-Participating) Insurance Billing Information:
Quarternote Counseling will accept and bill out of network (aka non-participating) insurance as a courtsey ONLY if the policy provides out of network benefits. Please check availabilty of out of network benefits on your policy. Clients using out of network insurance will receive a Good Faith Estimate and will be responsible for paying the difference between Quarternote's billed amount and the amount paid by insurance. Clients will be required to pay $100 each session, due at the time of service, and will owe any remaining amount after claims have been processed by the insurance company and any applicable insurance payment has been received. Please contact us if you have questions concerning out of network insurance billing.

If your insurance company is not listed above we are out-of-network providers. You may choose to forego using your insurance if desired. In some instances clients are able to self-submit claims to their insurance carrier. If a client chooses to do so, they may be seen as a self-pay client, and seek reimbursement from their insurance company of some monies paid. Quarternote is happy to provide a superbill to the client for this purpose, but we are unable to assist with the claim self-submission process, and are in no manner involved in that process or the outcome.

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 clients not using insurance a Good Faith Estimate no greater than 3 business days after the first appointment has been scheduled.

SECONDARY INSURANCE INFORMATION

What is your SECONDARY insurance? If your primary insurance company is not listed please select "Other/Not Listed" and provide the name in the space provided.

Anthem BCBS

CareFirst BCBS

United Healthcare

Anthem HealthKeepers Plus (a Medicaid plan)

Molina Complete Care of Virginia (a Medicaid plan)

United Healthcare Community Plans (a Medicaid plan)

Sentara Community Plans (a Medicaid plan)

Other/Not Listed

If you selected "Other/Not Listed" above, please provide the name of your SECONDARY insurance here

Client's name as it appears on the SECONDARY insurance card

Member ID number as it appears on the SECONDARY insurance card

Please enter the number as it appears on the insurance card, including all letters and numbers

Is the client the policyholder of this SECONDARY policy?

Yes No

SECONDARY policyholder's full name (first and last)

SECONDARY policyholder's relationship to the client

SECONDARY policyholder's Date of Birth

"Member Services" or "Provider Services" phone number on the SECONDARY insurance card

This is usually located on the back of the insurance card

INSURANCE INFORMATION

What insurance will be used?

Anthem BCBS

CareFirst BCBS

United Healthcare

Anthem HealthKeepers Plus (a Medicaid plan)

Molina Complete Care of Virginia (a Medicaid plan)

United Healthcare Community Plans (a Medicaid plan)

Sentara Community Plan (a Medicaid plan)

Other/Not Listed

(Please note that choosing this option means your insurance is one with which we do not particpate and are out of network providers).

If you selected "Other/Not Listed" above please provide the name of your insurance company here.

Client's name as it appears on the insurance card

Member ID number as it appears on the insurance card

Please enter the number as it appears on the insurance card, including all letters and numbers

Is the client the policyholder?

Yes No

Policyholder's full name (first and last)

Policyholder's relationship to the client

Policyholder's Date of Birth

"Member Services" or "Provider Services" phone number on the insurance card

This is usually located on the back of the insurance card

On what days might the client be available for appointments? (Please check all that apply) PLEASE NOTE: Weekend availability is limited, available as online appointments only, and is not available as an option for the client's first session.

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

What time of day is preferred? (Please check all that apply) PLEASE NOTE: This does not guarantee an appointment during these hours. This is to assist us with determining which therapist might be the best fit for the client.

Mornings (8am-12pm)

Afternoons (12pm-5pm)

Evenings (5pm-7pm)

Would the client prefer to be seen in person or online? PLEASE NOTE: ALL intake appointments (first appointment) will be held in-person only. Subsequent online services are not guaranteed to be available to all individuals

In person Online No preference

Desired characteristics in a therapist

Please describe to us what characteristics you would like in a therapist. For example, female/male, in their 20's/in their 40's, experience in certain areas, etc.

Please briefly describe the reason(s) for your interest in receiving therapy services.

To the greatest extent you are comfortable, please describe you reason(s) for seeking services. This information will be used by the Clinical Director to determine which therapist possesses the training and experience that is best suited for the client.

Your information will be encrypted.