Forms & Fees

For All Patients

Intake Form

For Ketamine Patients

Ketamine Form

Fee Schedule

Unfortunately, insurance will not cover this advanced treatment.

However, insurance may partially reimburse for Psychiatry and Psychology services.

Health Savings and Medical Savings accounts may be utilized.

  • Psychiatry Evaluation
  • Psychiatry Follow Up
  • Psychology Evaluation
  • Psychology Session
  • Ketamine Assisted Psychotherapy Treatment Session (Includes both providers present)
  • $444.44
  • $222.22
  • $277.77
  • $155.55
  • $888.88

Patients should please:
Print the forms with your signatures and bring them to your
appointment. You can also ownload them, fill them out, save them, and then forward them to info@epiphanypsychservices.com

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