If you are a new client, please download the first 6 of 8 forms, fill them out completely and bring them to your first session. Also bring a photo copy or picture of the front and back of your health insurance card(s) if applicable.
- Intake Information
- Electronic Payment Authorization
- Limits of Confidentiality
- Cancellation Policy
- Professional Service Agreement
If you would like us to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), please complete the Authorize to Release Health Care Information form. If the patient is a child and under certain circumstance you feel they might need restraining, please fill out the Restraint Agreement and bring that with you too.
The first six forms are required for each patient.
|Electronic Payment Authorization|
|Limits of Confidentiality|
|Professional Service Agreement|
|Authorization to Release Health Care Information|
If you wish to use health insurance, our services may be covered in full or in part by your health insurance provider or employee benefit plan. Please call your insurance company or employer in advance of receiving services to check your coverage. It is important that you understand what your costs may be for each session. Here are some helpful questions you may want to ask:
- Do I have mental health insurance benefits in my plan?
- What is my deductible and has it been met? If not, what will be my estimated out of pocket expenses?
- How much will my co-payment be for each session once my deductible is met?
- How many sessions per year does my health insurance provider allow?
- Is an authorization required to receive services?
- Do I have any EAP (Employee Assisted Program) sessions available?
As a convenience to you, we can bill your insurance company for the services we provide to you. You are financially responsible for charges that are not covered under your insurance plan. All required co-payments, co-insurance and deductible amounts are due at the time of service or when we are notified by your insurance company.
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