"One generation plants the tree, another gets the shade"

 

Gina Kramer, MFT

Therapy for Children, Adolescents and Adults

Contact Gina
707.334.4704
1434 Third Street, Suite #3A & #2B 
Napa, California 94559

Instructions:
Please download, print, review and fill out the required forms below then bring them with you to your first appointment. Thank you.

Child Intake Form

Adolescent/Adult Intake form

Informed Consent

HIPPA documentation

Authorization to Exchange Information

Authorization to Provide Treatment to a Minor

Electronic Communication Disclosure Form

COVID-19 Release Form

Good Faith Estimate Notice

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.