Goli Bellinger Forms

I look forward to meeting with you very soon. Please complete the forms and bring them to the first session or take the first few minutes of your session to fill them out after I greet you in the waiting area.

NOTE ABOUT PAYMENT: Your credit card is required at the time of scheduling your first session. It will not be charged until the day of your appointment. By providing your credit card you agree to the cancellation policy whereby you will be charged for your appointment unless 24-hour notice is given.

Checks or cash are preferred. A 4% discount is given for payment by cash, checks, or ACH direct debit. Please make checks payable to “Keith Miller Counseling, LLC.”  We also accept Visa, MasterCard, and Discover and American Express (see credit card form below).

The following three forms are REQUIRED for meeting with Goli Bellinger:

Client-Clinician Agreement- Bellinger

Client Data Form and Consent for Care – Bellinger

The following forms are OPTIONAL and used only when needed

Visa MasterCard Discover AmEx Form  (full fees apply to credit card users)

ACH Bank Debit Authorization Form (Discounted fees apply to ACH users or payment by check or cash).

Release of Information – Bellinger

Our consultation fees range from $175-$400 per hour, depending on the clinician.
We do not accept insurance, meaning we are not "in-network" with any health plans.
However, many of our clients submit claims to their out-of-network health insurance and receive 40-60% reimbursement.


We offer a live online Mindfulness-Based Stress Reduction and IFS course for couples.
Meets Tuesday nights September 6th - October 8th, 2022, 7-9pm EST

A HUGE savings compared to couples therapy

Learn More →