New Client Intake

Step 1 of 4 — Basic Information

First Name

Last Name

Preferred Name

Pronouns

Date of Birth

Contact Information

Address Line 1

Address Line 2

City

State

Zip

Time Zone

Mobile Phone

Email

Demographics

Administrative Sex

Gender Identity

Sexual Orientation

Race

Ethnicity

Marital Status

Employment Status

Emergency Contact

Name

Relationship

Phone Number

Step 2 of 4 — About You

Why are you seeking help now?

Please give more details about the issue you named above:

Have you ever experienced similar or other mental health symptoms before? If so, what was your experience like?

Has anyone in your family ever experienced mental health or substance use issues? If so, who was it?

Do you have any current or prior medical issues?

Are you currently prescribed any medications?

Do you now, or have you ever, used alcohol, tobacco, recreational drugs, or prescription medication other than as prescribed?

Who is in your family? What is your relationship with them like?

What social activities and relationships do you engage in?

What spiritual practices and cultural influences are important to you?

What was life like as you were growing up, both at home and in school?

What significant educational and work/volunteer experiences have you had?

Do you have any current or prior legal issues?

What strengths and abilities are you bringing to sessions?

What else is important to know about you?

Step 3 of 4 — Policies & Consent

Please review each document and check the acknowledgment box.

Good Faith Estimate ▼

Description of Services:

The services provided are individual or couple psychotherapy sessions with Jonah Taylor, LCSW.

Per-Session Fees:

Initial Intake Session 60 minutes

$225

Standard Individual Psychotherapy Session 53 minutes

$200

Standard Couples Therapy Session 53–60 minutes

$225

Extended Couples Therapy Session 75 minutes

$280

Payment for services is due at the time each session is rendered. Your credit/debit card will be securely stored and charged via Stripe.

Note: The actual number, length, and type of sessions will depend on your needs, how the work develops, and whether we are meeting individually or as a couple.

Estimated Treatment Range (required by federal law):
A typical course of therapy involves 12-24 sessions over 6-12 months, plus the initial intake. Based on the per-session fees above, the estimated total cost ranges from $2,625 to $6,825 depending on session type, length, and frequency. This estimate reflects the current fee schedule; your actual cost will depend on how often we meet and the type of sessions.

Your Rights:
You have the right to receive a Good Faith Estimate explaining how much your medical care will cost. If you receive a bill substantially higher than this estimate, you have the right to dispute it. Visit www.cms.gov/nosurprises or call 412-206-9080 for more information.

I acknowledge that I have received and understand this Good Faith Estimate. I have been informed of my rights regarding this estimate.

Consent for Psychotherapy Services ▼

The Center for Mind & Relationship
6425 Living Pl Suite 200, Pittsburgh, PA 15206
Also offering online therapy in PA, NJ, NM, and RI
412-206-9080 | mindandrelationship.com
Therapist: Jonah Taylor, LCSW | NPI: 1437891546

1. Nature of Psychotherapy
Psychotherapy involves a collaborative process aimed at improving mental, emotional, and behavioral well-being. It can lead to significant personal growth but may also involve discussing uncomfortable topics and experiencing difficult emotions. There are no guarantees regarding the outcome of therapy.

2. Therapist Qualifications
Jonah Taylor is a Licensed Clinical Social Worker (LCSW) with advanced training in Sex Therapy, Psychodynamic Psychotherapy, and Emotionally Focused Therapy for couples.

3. In-Person and Online Services
Online therapy is available to clients in PA, NJ, NM, and RI. You must be physically located in one of these states during sessions.

4. Confidentiality
All information shared is confidential, with exceptions for: duty to warn/protect, child or elder abuse reporting, court orders, supervision/consultation, and insurance (superbills).

5. Appointments
Sessions are typically 53-60 minutes, with extended couples sessions available when clinically useful. 48 hours' notice is required for cancellation. Late cancellations or no-shows incur the full reserved session fee.

6. Fees
Current fees are $225 for the initial intake session, $200 for standard individual psychotherapy, $225 for standard couples therapy, and $280 for extended couples sessions. Payment is due at the time of service. I do not bill insurance directly, but I can provide a superbill for possible out-of-network reimbursement.

7. Emergencies
Call 911 for emergencies. Crisis: 988 (Suicide Prevention) or text HOME to 741741.

8. Termination
You may terminate therapy at any time. Referrals will be provided if needed.

I have read, understood, and agree to the Consent for Services.

Notice of Privacy Practices ▼

Effective Date: June 1, 2025

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

How We Use Your PHI:
We may use your Protected Health Information for treatment, payment, and healthcare operations without prior written authorization. We may also disclose PHI as required by law, for public health activities, health oversight, judicial proceedings, law enforcement, and to prevent serious threats to health or safety.

Uses Requiring Authorization:
Psychotherapy notes, marketing, and sale of PHI require your written authorization.

Your Rights:
You have the right to request restrictions, receive confidential communications, inspect and copy your PHI, request amendments, receive an accounting of disclosures, obtain a paper copy of this notice, and be notified of any breach.

Data Security:
We use HIPAA-compliant Google Workspace with a Business Associate Agreement (BAA) for all electronic communications and records.

Complaints:
Contact Jonah Taylor at 412-206-9080 or [email protected]. You will not be penalized for filing a complaint.

I acknowledge that I have received and had the opportunity to review the Notice of Privacy Practices.

Financial Responsibility / Payment Authorization ▼

I. Financial Responsibility Agreement

Current fees are $225 for the initial intake session, $200 for standard individual psychotherapy, $225 for standard couples therapy, and $280 for extended couples sessions. Payment is due at the time of service. A 48-hour cancellation policy applies. Late cancellations and no-shows are charged at the full reserved session fee. This is a private-pay practice, and you are responsible for payment regardless of insurance reimbursement.

II. Payment Methods
Credit/Debit Card (stored securely via Stripe), Cash (in-person only), Check (in-person only).

III. Credit/Debit Card Authorization
I authorize The Center for Mind & Relationship to securely store my card via Stripe and charge it for: session fees at the applicable reserved rate and any late cancellation or no-show fee equal to the full reserved session fee.

Consent for Auto-Payment: Unless I make prior arrangements for cash or check, my stored card will be automatically charged on the day of each session or for any applicable fees.

I have read, understood, and agree to the financial policies and payment authorization outlined in this form.

Step 4 of 4 — Review & Submit

Almost done!

Please review your information, then click Submit. After submitting, you'll be directed to securely set up your payment method through Stripe (no charge).