Keith Miller Forms

I look forward to meeting with you very soon. Please complete the forms below and email them back to me prior to the first session. 

PAYMENT: Payment is expected prior to our first session and will be thereafter charged on the day we meet. Please submit a payment in the amount your counselor specifies. The fee for reserving your appointment with me are considered due 24 hours prior to your appointment time. Cancellations prior to this 24-hour-before-your-session point incur no charge. 

The following forms are REQUIRED for meeting with Keith Miller:

Client Data Form and Consent for Care – Keith Miller



The following forms are OPTIONAL and used only when needed

Consent for Release of Information

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.