Helpful Forms

If you're a new client, please complete the following forms and bring them to your first session.

  • Client Intake Form
  • Limits of Confidentiality/Cancellation Policy Form

 

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form:

  • Consent to Release Information Form

 


Client Intake Form  
 
Confidentiality and Cancellation Policy
 
 
CONSENT AND CONTRACT TO TREAT
 
This document is a legal agreement that clarifies my office policies.
 
Any appointment not canceled 24 hours or more prior to the scheduled time will be billed at the full charge for the appointment. _________(Initial)
Your insurance company cannot be billed for this, and you will be responsible for the full charge.  The only exceptions to this are hospitalization or the death of an immediate family member (spouse, child, parent).  Cancellations must be made by phone.
 
Though my e-mail address is on my business card, it is to be used exclusively for professional contacts.  Please do no e-mail me unless you have prior permission.  E-mails are not confidential.  If you do e-mail me, I will print a copy for your file.  Such communications may be intercepted on the internet, and I will not assume responsibility for loss of confidentiality through internet providers.
 
The patient or guardian will be expected to pay the full amount of the charge at the time services are rendered unless a prior arrangement has been made.  Co-pays for PPO clients must be made at the time services are rendered.  On occasion, I agree to bill patients on a monthly basis for services.  These payments are due by the tenth of the month.  A late charge may be assessed if payment is not received by then.  There is a $35 charge for returned checks.
 
I make every attempt to avoid court appearances because they severely interfere with the work of my other patients.  My fees for court appearances and court-related work are exactly double that of my full therapy rate.  I also charge for time in transit, any fees, lodging or airfare, or other expenses incurred by a requirement to appear in court.
 
There will be a $25 charge for calling in prescriptions to your pharmacy.  Patients need to make every attempt to get prescriptions filled during office visits.
 
Phone calls will be billed at the usual office rate for my time for other than refills and rescheduling of appointments.  Insurance usually does not reimburse such charges.
 
My full fees are listed below.  If I am a PPO provider for your insurance company, we must abide by their co-payment schedules.  However, if I experience difficulty in collecting from your insurer, I need your full cooperation in satisfying their requirements for payment.  If your insurer requires pre-authorization of benefits from me as a non-network provider, I will bill you for the time it requires me to obtain this authorization (or do it in session).  I prefer that you review any information prior to submission to your insurance because I am concerned about privacy with insurers.
 
Initial diagnostic interview-----------------------------------------------$300
Psychotherapy 45 minutes (with or without medication) ------------$190
Medication maintenance, 15-25 minutes--------------------------------$125
Legal fees--------------------------------------------------------------------$500 per hour
Phone calls of 15 minutes or less-----------------------------------------$50
 
I am not a Medicare or Medicaid provider.  My opting out of the Medicare system means that they will not reimburse any of my fees.  You are agreeing to pay me directly and forego insurance coverage by Medicare when you sign this agreement.
 
If you have any questions about these policies, I will be happy to discuss them with you.
 
I have read and agree to the above policies and procedures.  I also understand that from time to time fees may be increased with 30 days notice by advance in the mail.
 
__________________________________Patient___________________________Date
 
__________________________________Legal guardian________________________Witness
 
Consent and Contract to Treat
 
Developmental Questionaire  
Child Intake Form  
release form  
   

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