Secure Contact Form

For individuals interested in receiving services from Quarternote Counseling

Please correct the errors described below.

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. We will contact you as soon as possible, within three (3) business days of your submission. Fields with a red asterisk (*) are required.

NOTICE TO ALL POTENTIAL NEW CLIENTS: Effective September 26 2022, Quarternote Counseling does not have immediate availability for new clients, and our wait list is full. This is a temporary situation and we anticipate having availability for new clients in early December. We ARE still accepting submissions of this Contact Form. Upon having availability for new clients, we will contact individuals who have submitted this form, in the order in which they were received. However, we also strongly encourage you to seek services elsewhere during this time. If, come December, 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 703-675-5361. Thank you.

**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.

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 responding to this form submission and speaking to the client.

Please enter the number as it appears on the insurance card, including all letters and numbers
This is usually located on the back of the insurance card
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.

Your information will be encrypted.

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