New Therapy Client Forms and Information

Please complete the relevant intake and the forms linked below. Please fax, scan, or email me the completed intake form at least 2 business days before our first scheduled appointment.
Please bring the other completed forms to our first meeting.

Please allow 1.5 -2 hours for our first meetings
Subsequent therapy sessions are 1 hour
(We can schedule longer sessions as needed)

 

30I have a 24-hour cancellation policy.

Please provide at least 24- hours’ notice to reschedule an appointment. If you must reschedule a Monday appointment, please contact me by 5p on the preceding Friday.

Thank you for your consideration.

Insurance does not pay for late cancellations or missed appointments.

Insured clients are charged $75 for missed initial evaluations or those canceled with less than 24-hours’ notice and $50 for missed one hour therapy sessions or those canceled with less than 24-hours’ notice

Self-pay clients are charged $100 for missed initial evaluations or those canceled with less than 24-hours’ notice and our agreed upon hourly rate for missed one hour therapy sessions or those canceled with less than 24-hours’ notice.

I appreciate your understanding.

Click the links to download the Forms

New Client Information Form

Assignation of Benefit

Practice Guidelines and Consent for Treatment

Fee Agreement
Please enter your co-pay or the session fee we agreed upon

Rates, cancellations, and insurance information

HIPAA information
Please return only the signature page

Release of information
Please complete this if you’d like me to speak with your attorney, physician, previous therapist (or anyone else)

Adult intake (age 19-99)

Adolescent intake (age 13-18)

Please remember to fax/scan/email me the completed intake form at least 48 business hours before our first appointment and bring the other completed forms when we meet.

Please feel free to contact me with any questions about these forms or
anything else.  Ethical and legal guidelines prohibit me from
meeting with new clients without these completed forms. 
Thank you for your cooperation.
 

Email: amyebrown.lpc@gmail.com
Fax: 610.566.3274

Thank you!