Please print out the following forms and bring them to your first appointment.
Please use black ink to legibly complete and sign this form.
Client Privacy Notice
Sign to indicate you have received this notice. It is a good idea to make yourself familiar with it.
Please read this carefully and be prepared with any questions, comments or concerns you have. We will discuss them during our first session and then sign it together.
Credit Card Authorization
This is kept on file for all clients but only used as indicated on the form.
Third Party Payer
If someone other than you and/or your insurance will be paying for services, you
and the third party payer should complete and sign this form.
Because I am a licensed clinical psychologist, most services are covered by medical insurance plans. You may wish to contact your insurance company to learn what your exact coverage is. Here are some questions you may want to ask:
- Do I have mental health benefits?
- What is my annual deductible and has it been met?
- Is the deductible for mental health services separate from the deductible for physical health services?
- Is my deductible based on a calendar year or another 12-month cycle?
- How many psychotherapy sessions per calendar year does my plan cover OR how many neurofeedback sessions per year does my plan cover (whichever applies)?
- Does my plan cover neurofeedback, and if so, are there differences between how it and psychotherapy services are paid?
- How much does my plan cover for an out-of- network provider?
- If coverage is expressed as a percentage, is that percentage based on the actual fee charged?
- If my coverage is a percentage based on “reasonable and customary fees”, what is the maximum fee for a 45-50 minutes individual psychotherapy session (CPT or service code 90834) OR a neurofeedback session (CPT code 90876)? These amounts vary considerably among insurance companies, can often be very low and may cap the actual amount you get reimbursed.
As an out-of-network provider, I collect fees directly from you and provide you with a Super Bill with all the information needed for filing your insurance claims.