Client Resources

Forms · Financials · Links

New clients, please be sure to complete and print out all required forms prior to your first visit.

Forms

Please note that there are forms that need to be completed prior to your first session. Copies of these forms are kept at my office,  if you do not have access to a computer or a printer. Also, please understand that there may be other documentation required on a case-by-case basis.

The following three forms should be completed prior to the first therapy session by all parties, regardless of age.

Patient Information
HIPAA Notice of Privacy Practice
Contract for Therapeutic Services

The following form is voluntary, to be used for ease of payment.

Credit Card Authorization for Payment

The following form is to be completed by a parent/guardian for clients under the age of 18.

Developmental History Questionnaire

Financials

Private Pay
I accept all major credit cards, checks, and, of course, cash. My standard fee is $110.00 for 45-50 minutes. If applicable, there will be a $35 returned check fee.

Insurance
BDA|Morneau Shepell (EAP)
ComPsych (EAP)
ESPYR (Formerly EAP Consultants) (EAP)
Medi-CAL (Medicaid)
Medicare
TriWest Healthcare Alliance Veterans Choice Program
Health Spending Accounts (HSA Credit Cards)

I am currently in the process of applying to various insurances; however, pending membership on these panels, many insurance companies provide an Out-of-Network (OON) benefit for PPO plans, but not HMO plans. If this is something you wish to pursue, let’s discuss how to access these benefits.

Finally, if you must cancel your appointment, please do so prior to 24 hours, as anything less than a 24 hour notice will incur payment of full fees. Additionally, if you “no show” to your appointment, you will also incur payment of full fees. After three “no shows” I may remove you from the schedule.

2-1-1 San Diego

Alcoholics Anonymous

Narcotics Anonymous

National Alliance on Mental Illness (NAMI)

Substance Abuse and Mental Health Services Administration (SAMHSA)