New Patients
may download and complete the following six forms to bring to the initial appointment. If preferable, patients may also come 30 minutes prior to the initial session to complete forms in the waiting area. The doctor will review all the paperwork during the first meeting, and will address any questions at that time. If patients are seeking insurance authorization for psychological services, it would be helpful to contact them in advance by calling the number on the back of the insurance card to ensure benefits coverage. You will also need to bring your insurance card to the first appointment.
1. Face Sheet (Demographics/Insurance Information)
2. Treatment Agreement (Services Contract)
a. QEEG/Neurotherapy
b. Psychotherapy, Testing, Groups, Classes
3. Authorization (Release Form)
4. Privacy Policy
5. Request for Confidential Handling of Private Health Information
6. History Questionnaire
a. Adult
b. Child/Adolescent
c. Chronic Pain
Fee Schedule
| Initial Evaluation/Consultation |
$150/hr* |
| Individual Therapy |
$125/hr |
| Family Therapy |
$125/hr |
| Couples Therapy |
$125/hr |
| Premarital Education Classes |
$125/hr |
| Psychological Testing |
$125/hr |
| Forensic work |
$150/hr |
| QEEG |
$750 |
| Neurotherapy |
$125/hr |
| Biofeedback |
$125/hr |
| Pre-surgical Evaluations for Weight Loss |
$275 |
| Report Writing |
$125/hr |
| Phone Consultations |
$40 per 15 mins |
| Groups |
$40 per session |
| Missed Appointments |
$125 |
| Canceled 24hrs notice |
$125 |
| *A standard clinical hour is 45 to 50 minutes. |
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