Professional Documents
Culture Documents
Practice in Child, Adult, and Couples Psychotherapy Consultant, Child Health Services
Information you provide here does not constitute a contract between us. It is for initial
administrative only. My practice accepts some forms of insurance. However, it is important to
understand that most insurance plans place limitations on the services they cover. Also, in order
to allow additional sessions, they may require that I periodically discuss clinical information
about your care. I cannot safeguard the privacy and use of information given to insurers. For
this reason, some individuals choose to not use insurance for their psychological care. If you
chose to use insurance, we will verify your coverage. On occasion customer service
representatives may give inaccurate information. Therefore, if you chose to use insurance, it is
in your best interest to inform yourself about which outpatient psychological services are
covered under your plan.
A. I wish to pay for psychological services out of pocket.
B. I wish to access an insurance benefit.
Yes
Yes
No
No