New Client Paperwork

We Meet Again!
Whether you are a new or returning client, or perhaps browsing online resources for more information about an issue or the world of psychology, I’m excited that you have found your way to my site. My hope is that you enjoy what you see here and find the information to be valuable whether for yourself or someone else you encounter. For new clients interested in scheduling an appointment, I would be honored to join your healthcare team as you take steps toward enhancing the quality of your life!

New Client Paperwork

Before we get started, please take 30-60 minutes to print out, review, complete, & sign the following forms. Please bring completed forms with you to our first appointment along with any questions and/or comments you may have. Your doing so will help to streamline our time together in our first meeting, focusing more in depth about your specific reasons for coming in and how we might formulate our work together. I appreciate your cooperation and look forward to the pleasure of meeting you with excitement and commitment to helping you achieve your personalized goals.

All Clients

  • Please download, review, print, & sign the signature page of the HIPAA & Informed Consent (i.e., Exhibit C).
    Before signing the Privacy Policy, please also read the Notice of Protected Health Information Practices (i.e., Exhibit B: Privacy Policy, amended 2013). These forms should be completed by parent(s)/guardian(s) if client is a minor under the age of 18.

  • Please download and complete the INTAKE FORM. This document includes one copy of the needed release of information forms in case you’d like me to consult with other providers with whom you are working. Additional copies may be accessed and printed here: Release of Information and Release for Exchange of Information.  

Payments are accepted in cash or check.
I also accept credit card payments, though there is a nominal fee for each payment.

Weight Loss Patients

  • If you are interested in the behavioral weight management program for weight loss, please message me for additional paperwork on your weight history. Note: This form may take an additional 30-45 minutes to complete. For additional information on this program, please click here.

Clients Who Are Minors (17 years of age or younger)

 Please print and complete this Consent Form (Minors) in addition to the above consent and intake documents completed by parent(s)/guardian(s)..

Insurance Coverage

While I am not paneled with insurance companies, many patients are eligible for out-of-network reimbursement for mental health and/or health and behavior change services after an initial deductible is met, which varies by policy. Whenever requested, I am happy to provide diagnostic codes and billing information that you may use to pursue partial reimbursement for services. Please note, many corporate wellness plans offer reimbursement and/or the opportunity to set aside pre-taxed monies (i.e., flexible spending accounts) to offset the cost of health-related services. I encourage you to consult your Human Resource office for additional information. Services may even be tax-deductible; I encourage you to consult your CPA or tax consultant. I am happy to call your insurance company on your behalf to inquire about your benefits, though it is ultimately the client’s responsibility to confirm benefits with insurance company/work and to complete paperwork for reimbursement of services.

Whether or not insurance reimbursement is pending, payment is non-refundable and due in full at the time of each session. I respectfully request cash or check for payment. Credit cards are accepted, however, a small fee is charged per transaction.

Emergency Services

Please note, emergency services are beyond the scope of this practice. If a life-threatening emergency arises, clients are directed to immediately contact 911 or go to the nearest emergency room. In the event of crisis or suicide risk, clients are encouraged to contact the EMPACT Suicide Prevention Center at (480) 784-1514 
or 1-800-SUICIDE (i.e., 1-800-784-2433).

If you are a veteran and prefer to speak directly with another veteran regarding your feelings, please call the Veteran’s Crisis Hotline at 1-800-273-8255, option 1 to be directed to supportive staff 24-7. Please also be aware that as a veteran you are eligible for a vast array of outstanding mental health services and supportive programs. These programs are offered through your local VA and are often available for minimal or no out-of-pocket cost. Please consult with VA registration/enrollment staff for more information. In Phoenix, you may call 602.277.5551, dial 0, and ask the operator to direct you to registration, enrollment, or other desired department. Remember, you are not alone!