Info & Forms
Before we start our journey together, please print and complete all the forms in this intake packet. If you don’t have access to a printer, you may e-mail your completed forms to me at firstname.lastname@example.org.
Intake Packet Contents:
- Client Information Form & Concerns Checklist
- Informed Consent
- Notice of Privacy Practices
- Financial Agreement Form
The first time we meet, I’ll ask you to arrive about 10 minutes early to complete some basic paperwork to help us get started. The first 30 minutes are a free consultation where we’ll get acquainted by discussing what you’d like to talk about in therapy. It’s absolutely no pressure- and you’re welcome to ask me any questions at this time. At the end of the consultation, if it seems like we can work well together, you’ll have the opportunity to stay for the remainder of the 50-minute therapy hour or schedule another session. Because this appointment goes by quickly, I recommend that you allow yourself plenty of time to look for parking and find the building by arriving early.
I accept payment by cash or check. Services can be paid for in advance, or at the end of every session.
I am an out of network provider for many PPO medical insurance plans. Upon request, I will also provide courtesy billing to my clients’ insurance companies. This means that clients may only need to pay their portion, and do not have to pay the full amount up front and wait for reimbursement, as is often the case. Some of the insurance companies I have billed include (but are not limited to):
- Aetna PPO
- Anthem Blue Cross PPO
- Cigna PPO
- Coventry Health
- GEHA PPO
- Coventry Health PPO
It is helpful to ask your insurance company the following questions to expedite the paperwork process:
- What is my deductible?
- Have I met my deductible? If not, what is the remainder before my deductible is met?
- How many sessions are covered?
- What percentage of the cost will be covered when I see an out of network provider?
- Are benefits per calendar year?
I offer a phone consultation free of charge. For in person consultations, the first 30 minutes are free and if you choose to continue on for the full hour, there will be a full fee session charge. You may contact me directly to inquire about current rates. In rare circumstances such as extreme financial need or being a full time student, I may provide my services at a reduced rate during non-peak hours (typically during the day between 10am and 3pm) to those who can demonstrate this need. If circumstances improve, I ask these clients to adjust their fee accordingly. This allows me to continue providing discounted services to clients who may be in serious need of therapy but unable to otherwise afford it.
I request 24 hours notice for a session cancellation. A good rule of thumb is to let me know as soon as possible (sooner than 24 hours preferably) as a courtesy to me and to other clients who may want to schedule at that time. Every client gets one emergency cancellation forgiven without charge, after that, there is a full fee charge for sessions cancelled within 24 hours.
I accept text messages from clients for short messages and scheduling changes. Please note that technical issues do arise and that on occasion I do not receive text messages that are sent to me, or messages I send do not go through. If you do not hear back from me within 24 hours of texting, please assume I did not receive your text, and re-send it or give me a call instead. Cancellations must be made over the phone. In an emergency, please call 911.
Clients are welcome to send me basic information via email (check-ins, list of medications, etc.). Due to the volume of email I receive, I cannot guarantee that I will be able to respond to every message. Be aware that email is not considered a secure form of communication, nor is it considered an appropriate medium for in-depth discussion of therapeutic issues. If in doubt, please call me at 949-682-9474. In an emergency, please call 911.
Social media outlets such as facebook and twitter are not considered appropriate means for seeking therapeutic support or advice. Clients may follow me via social media outlets (twitter, facebook, etc.) at their own discretion; however, communicating with me via social media outlets is discouraged. To maintain my clients’ confidentiality, I do not follow back, retweet, or otherwise acknowledge or communicate with my clients via social media. I do not respond to requests for emergency support from social media contacts. In an emergency, please call 911.