General Office Policy "*" indicates required fields Your Name First Last Insurance* Insurance Acknowledgment Almost everyone I see gets reimbursed through their insurance using Out-of-Network benefits. You may want to check with your insurance company to see if you have Out-of-Network benefits prior to therapy. You may also want to find out your deductible, what percent of each session is covered and if there is a limit to the number of sessions allowed. I can give you a receipt for your visits which will include all the necessary information needed by the insurance company. Receipts are given quarterly, at the end of therapy, at the end of the year or when you do your taxes. You can request a time that works for you. Once you have a receipt from me, you can send it to your insurance company for reimbursement. The address of where to send it, is usually on the back of your insurance card. Fees / Session Length* Fees / Session Length Acknowledgment The fee for each session is agreed to in advance, and required at the time of service. Hourly sessions last approximately fifty (50) minutes. An hour and a half session would last 75 continual minutes. Credit card payment is preferred. Cancellations* Cancellations Acknowledgment For all scheduled appointments, 24 hour notice is required or you will be charged the full hourly fee. For any first time appointment where a 24 hour cancellation notice is not made or if the client does not show, there is a $95 charge for missing the reserved 50 minute appointment time. Emergency Policy* Emergency Policy Acknowledgment My practice is by appointment only as opposed to crisis intervention. If you are in a crisis and want to talk to me, please call me and leave a message. I check my voice mail and messages several times a day and can be reached by calling (713) 823-4001. In case of an emergency and you can not reach me, you can call 911, United Way Crisis Hotline (713) 228-1505, MHMRA Crisis Unit (713) 970-7000 or go to the nearest hospital emergency room.Notice of Privacy Act* Notice of Privacy Act Accepted Notice of Privacy Act Denied Please confirm that you have been offered a copy of the Notice of Privacy Act. Confidentiality* Confidentiality Acknoledgement Zoom and other forms of media are not encrypted. By initialing, you are saying you give permission to have sessions via this media and that you give permission and are comfortable receiving information from me, including but not limited to handouts, articles and therapy receipts via internet. Acknowledgement of General Office Policy I designate that I fully understand the office policies regarding insurance, fees, cancellations, emergencies, insurance and using zoom and the internet.Signature