Please fill out this form and email it to me before your appointment. Thanks.

MM slash DD slash YYYY
MM slash DD slash YYYY
Name of insurance company

Be sure to read the following and sign below -keep scrolling down

Policies and Procedures

CONFIDENTIALITY: The content of your sessions is private, except when there is a threat of harm to self or others, or if there is a history of abuse involving minors. Your written permission is required for me to share any information about your treatment with anyone else, such as your doctor, family member or lawyer. In instances when I have to complete a form for insurance authorization, I will develop it with you so you will know its content. All files are kept secure.

NOTICE OF CANCELLATION: The time for your appointment is being held for you and there are others who would like to have that time if you cannot be present. Therefore, if you are unable to make a scheduled appointment, cancellations of at least 48 hours prior to the appointment will be appreciated so that someone on the waiting list can fill your time slot. All cancellations made within less than 24 hours prior to the scheduled appointment which cannot be filled from the waiting list will result in the full charge being made to you. Insurance companies will not reimburse for a missed appointment. Please note that weekends and holidays are not considered as part of the notice time, so that a Monday cancellation must be made by Friday of the previous week.

EMERGENCIES: This practice does not provide 24-hour, seven day a week emergency care. I will return your calls in a timely manner but in the event, I cannot be reached during an acute emergency, please use the services of your local hospital or the hotlines in your community.

FEES: Fees are due at the beginning of each consultation so that we can end the session on time and I can be punctual with the next patient. My fee is $155.00 per 50–55-minute session.

INSURANCE REIMBURSEMENT:  I suggest that you verify your insurance benefits, specifically your deductible and co-pay. Insurance companies do not pay for marriage therapy.

I have read and understand the above policies. I understand that payment is to be made at the beginning of each consultation and that I am financially responsible for all scheduled appointments unless a minimum of 24 hours’ notice, as described above, is given.

Typing out your name constitutes a signature
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.