For New Clients

Insurance

Dr. Peck and Q Counseling Services are “in-network” for a variety of health insurance programs, including:

  • Aetna
  • Blue Cross and Blue Shield
  • Cigna
  • HealthNet / MHN
  • United Healthcare
  • Medicare
  • various EAP providers.

If in-network, we will bill your insurance provider directly; at the time of service, you pay your co-pay.

If your insurance company is not listed above, please check with your provider to see if we are contracted with them. If not, and you have out-of-network coverage, we will provide you with a bill that you can submit to your insurance company for reimbursement.

Rates

Per current insurance billing protocol, a 45-mintue session is billed at $130 and a 60-minute session is billed at $160. Other billing session protocols and fees, including longer sessions, can be discussed directly with Dr. Peck.

For non-insurance clients, please discuss rates directly with Dr. Peck. Because of his beliefs about caring for your community, Dr. Peck does offer some reduced rate, sliding scale fee, options.

Privacy & Confidentiality

In compliance with the Health Insurance Portability and Accountability Act of 1996 and professional ethics, Dr. Peck and Q Counseling maintain the privacy and confidentiality of your health information. It is the law.

Further, effective counseling requires privacy and confidentiality; these are essential to a trusting therapeutic relationship. During your first session, Dr. Peck will review, briefly, with you the rules of confidentiality.

Forms

Intake

Please complete this form and bring it to your first session. You can either complete it on your computer or print and handwrite your responses.
»Download«

Consent for Treatment

Please review the practice information, print and sign the final page and bring it to your first session.
»Download«

Health Insurance Portability and Accountability Act (HIPAA)

Please review the HIPAA information, print and sign the final page, and bring it to your first session.
»Download«

Release of Information

to be completed as needed
This form is required if information will need to be released to another, such as an attorney or other healthcare provider. If you are uncertain if this form will need to be completed, please discuss it with Dr. Peck.
»Download«