I agree to the below terms and conditions:

You give New Hope Counseling, Inc. and Jim Valeri, LMHC permission to communicate with your insurance company (if applicable).

This is a consent form for the insurance company's claim processing (lines 12 & 13 on the HCFA 1500, if applicable).

You also give Jim Valeri, LMHC and New Hope Counseling permission to charge your credit card on file for any services not covered by your insurance (per session fee of $150), or for any copays incurred through counseling services.

Every effort, within reason, will be made to work with you and your insurance company to cover payment for services rendered.

A fee of $50.00 will be charged for cancellations of less than 24 hours.

Our Privacy Policy can be viewed here.
By providing my phone number, I agree to receive text messages from the business.

You may opt out of emails and text messages at any time, but we recommend you keep these on for session reminders.