FORMS & POLICIES

There are some administrative forms that need to be completed prior to your first session. Please complete the applicable forms below for the identified client and bring them with you to your appointment. Please note, HIPAA forms and the Informed Consent Agreement are required for all patients, regardless of age.

CHILD BACKGROUND INFORMATION

(Under Age 18)

ADULT BACKGROUND INFORMATION

HIPAA FORMS

MARYLAND INFORMED CONSENT AGREEMENT

NEW YORK INFORMED CONSENT AGREEMENT

POLICIES

Payment Information

Payment is due at each session by cash, check, credit card or HSA debit card.

Balances over thirty (30) days are considered outstanding, and a 5% fee will be applied each week after that.

Please refer to the Service Agreement for further details about payment policies.

Privacy Policy

Upon request, you can obtain a copy of the National Privacy Principles/Health Privacy Principles, which describe your rights and how your information should be handled.

Insurance

I currently do not participate with any insurance company. Since insurance coverage varies, please check with your provider to see if they cover or reimburse out-of-network services. I will write treatment plans upon request.

Cancellation Policy

Scheduled appointments may be canceled at no charge with a minimum 24-hour notice. Less than 24-hour notice or no-shows will be charged a cancellation fee as outlined in the Services Agreement.