Insurance Intake Form (Page 2 of 2) in pdf

Expectations from Therapy: Client’s Responsibilities

People utilize therapy to help change what are often significant aspects of themselves (attitudes,

behaviors, emotions, etc), their relationships (marriage or significant other relationships such as

with parents, friends, children, other relatives, etc.) or other circumstances in life (employment,

living environment, etc.) in order to reduce or alleviate problems and to lead a more fulfilling life.

As a client, you will be expected to take an active role. As a professional, I can assist in effecting

change, but cannot guarantee a specific outcome. You will determine the direction and be

ultimately responsible for growth. If at any time you are dissatisfied with your therapy, please let

me know in order that we can work together toward a solution.

SERVICE AGREEMENT

1. Appointments must be canceled at least 24 hours prior to the appointment or the client

will be billed for that session.

2. Out-of-office consultations---hospital visits, court appearances, or other types of

consultations (which require the therapist to leave the office to provide counsel or

consultation) can be provided to the client at a fee of $250 per session hour.

3. On services covered by insurance, you, as the client are responsible for payment.

4. Consultation with referral sources on the client’s behalf will be billed at the existing rate

for the portion of the time utilized to provide the consultation.

5. Therapy sessions consist of a 50-minute “hour”. If session last longer than 50 minutes,

they will be billed on a pro-rated basis.

6. Fees for individual therapy per 50-minute session is $90.00. The Fee for marital/couple

therapy is $130/session.

7. Payment is due when services are received. Make checks payable to Lena Pearlman,

LCSW.

8. If for any reason payment for services is not received within thirty (30) days after the

services were rendered, there will be a $25 per month carrying charge.

9. There will be a $25 charge on all returned checks.

I understand the above policies and agree to these provisions.

Signed____________________________________________________________

Date: ________________________________

Acknowledgment of Receipt of Notice of Privacy Practices

Insurance Intake Form Page 2