Payments & Insurance

Bala Empowerment, LLC is currently in the process of credentialing with major insurance providers, including Medicaid and Medicare.
Major Insurance Accepted: Once credentialing is complete, clients will be able to use their insurance benefits for covered services.
Private Pay: Clients may choose to pay directly for services. Payment is due at the time of each session. I accept a variety of payment methods, including credit/debit cards.
Out-of-Network Benefits: For clients with insurance plans not directly accepted, I can provide a detailed receipt (“superbill”) that may be submitted to your insurance company for possible reimbursement.
Therapy is an investment in your well-being, and I strive to make the process transparent and accessible. Please reach out with any questions about fees, insurance coverage, or reimbursement options so we can find the best path forward together.

Telehealth Services

Individual Therapy

(Children, Adolescents, Teens)

Rate: $150 per 53-minute session

Psychotherapy Intake & Assessment

Rate: $200
Your first session is a comprehensive appointment where we’ll discuss your history, current concerns, and goals for therapy. This helps us create a personalized plan tailored to your needs.

Psychotherapy Follow-Up

Rate: $150 per session
Ongoing sessions provide continued support, helping you build skills, process experiences, and move toward your goals.

Authorization to Bill Insurance

Client

Guardian (if Minor)

Phone

Address

Insurance Company

Policy No

Doctor

Clinic

Phone

Location

I, the undersigned, hereby certify and attest that I have sought evaluation, treatment, or medical advice from the staff at the clinic named above. I therefore authorize the medical staff and personnel to release my or my minor child's medical information to the insurance company listed above for the purpose of determining and receiving benefits for medical bills.

I understand and acknowledge that the medical staff will submit my claim to the insurance company on my behalf. I further understand that I will be held responsible for any amount of my medical bills not covered by insurance policy or claims, and that I will be responsible for paying all deductibles, fees, co-payments, and co-insurance payments required.

I understand that any portion of my medical bills not covered by insurance will be billed to me at the address I have provided above. Non-compliance or defaulting on payments may result in denial of service and/or a legal claim against me for non-payment.

Policy Company Address

I have read, understood, and agree to the authorization above.

Signature

Clear Signature

Date