FORMS

Below you will find all the forms you need for your initial session. Please feel free to contact me if you have any questions or concerns. Thank you!

A. New Patient Intake Form

Please print and complete this form prior to our first appointment.
CLICK TO VIEW AND PRINT

B. Telehealth Consent Form

Please print and complete this form prior to our first telehealth (phone or video) appointment.

C. Insurance Release Form

Please print and complete this form prior to our first appointment in Peachtree City or Atlanta

D. Credit Card Form

Please print and complete this form prior to our first appointment in Peachtree City or Atlanta.


FEES / MEDICAL INSURANCE ACCEPTED

I work with several insurance plans, and can also help you submit billing as an out-of-network provider. Cancellations must be made a minimum of 24 hours prior to the scheduled appointment time to avoid the $50.00 cancellation fee.

SELF-PAY (MEDICAL INSURANCE NOT USED)

The fee for self-paying clients is $125-$150 per session.

METHODS OF PAYMENT ACCEPTED

Payment methods for self-pay and insurance co-payments include cash, checks, health savings accounts, Square, PayPal, American Express, Discover, Mastercard, and Visa.

ACCEPTED INSURANCE PLANS

Current accepted insurance plans include:

  • Aetna

  • BlueCross and BlueShield

  • Humana

  • Medicare

  • Most Medicare Supplemental Plans

This list can be updated from time to time, so please check with us to see if we are an accepted provider within your network.

CANCELLATION POLICY

Cancellations must be made a minimum of 24 hours prior to the scheduled appointment time to avoid the $50.00 cancellation fee.

In compliance with the No Surprises Act that goes into effect January 1, 2022, all healthcare providers are required to notify clients of their Federal rights and protections against “surprise billing.”

 This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects not to use their insurance.

 Additionally, we are required to provide you with a Good Faith Estimate of the cost of services (attached). It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, attached you will find a fee schedule for the services typically offered by your therapist, and we will collaborate with you on a regular basis to determine how many sessions you may need. 

It is a Federal requirement that we have each client sign this form to begin/resume treatment. Please sign and date before your next appointment and return the signed document before your next appointment. If you have any questions, please don’t hesitate to ask.