Miles Diller Required 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. When we are not able to meet in person, payments are made online here (not subject to our normal discount for paying by check or cash in-person.) We accept Visa, MasterCard, Discover and American Express.

If we meet in person, 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.”

Forms for Miles Diller:

Registration Form

Release Form

Consent Form

Instructions for how to use Doxy (PDF for online portal for video sessions)

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.