Mark Jacobsen 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: Payment is expected at each session. Checks or cash are preferred. Please make checks payable to “Keith Miller Counseling, LLC.”  A 4% fee discount is given for payment by check, cash, or ACH bank debit. Please make checks payable to “Keith Miller Counseling, LLC.”  We also accept Visa, MasterCard, Discover and American Express (see credit card form below).  Having your payment ready before your session is helpful to keep your session time free from administrative details.

The following three forms are REQUIRED for meeting with Mark Jacobsen:

Jacobsen Client-Clinician Agreement

Jacobsen Client Intake Form

Physician Release of Information


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).

Jacobsen Consent for Release of Information

Our fees are between $200-$400 for 50 minutes, depending on your counselor. 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.