Forms for New Patients

Please print and fill out:

Client in-take form

Signature form. This form states that you have read the HIPAA Notice of Privacy Practices

 

Please read (no need to print out):

HIPAA Notice of Privacy Practices


 

Policies

Payment 
Cash, checks and credit cards are accepted for payment at the time services are provided.  

Sessions generally run from 45-60 min depending on age, issue and modality.   

 

• Psychotherapy (55-60 minutes) $250

• Psychotherapy (45 minutes) $200

• Family Therapy (55-60 minutes) $250

 

If financial concerns arise during treatment, please feel free to discuss it with me. 

 

Insurance 
I currently accept Anthem BCBS, Cigna and Husky insurance. 

For other insurance carriers, I will gladly provide you with a bill of service which you can submit to your insurance provider for reimbursement as outlined by your plan.

Cancellation Policy 
If you cannot make your scheduled appointment, please notify me at least 24 hours in advance.  If you miss your therapy session, and you have not notified me at least 24 hours in advance, you will be required to pay the full cost of the session.  

In Case of Emergency 
In the event that you are faced with an emergency, please call 911 or go to your local emergency room for immediate attention.  Please contact me as soon as you can to inform me of the event.

Confidentiality & Privacy Policy 
The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission. Exceptions include:

Suspected child abuse or dependant adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.

If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim, as well as damage to property as required in the State of Connecticut.

If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in insuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.