Please review the Notice of Privacy Practices then COMPLETE & FORWARD to me via Email or Fax all pages of the new client forms below prior to your initial appointment. If you do not have access to fax or scanning/emailing, please bring these completed forms with you to your first session.
| new_client_forms_and_checklist.pdf |
| notice_of_privacy_practices.pdf |
In order to verify your mental health benefits before the first session and submit claims on your behalf, I will need to receive by fax (919-883-5818) or email (mindfulawakening108@gmail.com) a copy of the front and back of your insurance card, along with your full name, date of birth and the name and date of birth of the subscriber if someone other than you. Please allow at least 3 business days before your appointment date for this to be completed.
Due to the confidential nature of therapy, you will need to complete and sign the Authorization to Release/Exchange Information Form (see below) ONLY if you would like me to discuss your treatment with another provider/individual or receive information about your treatment from another provider/individual.
Due to the confidential nature of therapy, you will need to complete and sign the Authorization to Release/Exchange Information Form (see below) ONLY if you would like me to discuss your treatment with another provider/individual or receive information about your treatment from another provider/individual.
| authorization_to_release_or_exchange_mh_info_06292016.pdf |
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DARING WAY™ & RISING STRONG™ GROUP PARTICIPANTS ONLY:
If you are interested in attending a Daring Way™ or Rising Strong™ group offering, please complete the following form and fax to (919) 883-5818 or scan and email to mindfulawakening108@gmail.com:
DARING WAY™ & RISING STRONG™ GROUP PARTICIPANTS ONLY:
If you are interested in attending a Daring Way™ or Rising Strong™ group offering, please complete the following form and fax to (919) 883-5818 or scan and email to mindfulawakening108@gmail.com:
| participant_information_form.pdf |
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APPOINTMENTS:
Appointments are scheduled on a weekly or biweekly basis unless arranged otherwise. Your initial session with me is an opportunity for me to gather information about:
* what brings you to therapy at this time;
* your current and past experiences that are having an impact on you and your life;
* your strengths, skills and goals.
Your initial session is also an opportunity for you to ask questions, evaluate your readiness for change, and see if we are a "fit" to work together as you pursue growth and change in your life at this time. If the fit doesn’t feel “right” for you or if I do not believe I have the skills to help you, then I will be happy to provide you with referrals.
Because therapy is such an investment of time, energy, emotions and finances, I ask that together we re-assess by your third or fourth session if we are still a good therapeutic match - are my personal style, clinical approach, skills and experience a good fit for your needs? OR can the challenges you are facing be more adequately addressed by another clinician with a specific expertise or different style?
APPOINTMENTS:
Appointments are scheduled on a weekly or biweekly basis unless arranged otherwise. Your initial session with me is an opportunity for me to gather information about:
* what brings you to therapy at this time;
* your current and past experiences that are having an impact on you and your life;
* your strengths, skills and goals.
Your initial session is also an opportunity for you to ask questions, evaluate your readiness for change, and see if we are a "fit" to work together as you pursue growth and change in your life at this time. If the fit doesn’t feel “right” for you or if I do not believe I have the skills to help you, then I will be happy to provide you with referrals.
Because therapy is such an investment of time, energy, emotions and finances, I ask that together we re-assess by your third or fourth session if we are still a good therapeutic match - are my personal style, clinical approach, skills and experience a good fit for your needs? OR can the challenges you are facing be more adequately addressed by another clinician with a specific expertise or different style?
APPOINTMENT POLICIES:
Missed or Late Cancellations:
In order to guarantee you a regular time and maintain an organized practice, I schedule a single weekly (or biweekly) time slot for you. A minimum of 24 hours or one full business day's notice (whichever is greater) is required to cancel an appointment (example: to cancel a Monday 8:30 AM appointment, provide notice of the need to cancel no later than 8:30 AM on the Friday before).
Missed sessions are not billable to insurance & will be charged directly to you. When appointments are missed or canceled with less than the greater of 24 hours' or one full business day's notice, , you will be responsible for paying the equivalent of your insurance plan's allowable amount for the missed session. If you do not use insurance, the full session out-of-pocket fee is applied. Regarding a planning error or preventable miss, the policy holds. Missed Session or Late Cancellation Fees can be waived for emergency issues only. If a pattern of frequently canceling appointments with only 24 hours notice begins to emerge, I reserve the right to require a minimum of 48 hours or two full business days’ notice to avoid a late cancellation fee.
Termination Related to Missed Sessions:
If you miss 2 sessions in a row and I do not hear from you within two days after the second missed session, I will assume that you have terminated services with me and will release your scheduled appointment times. You may contact me about the possibility of resuming work with me after that, but I cannot guarantee I will have current availability or your previously held appointment time.
In order to guarantee you a regular time and maintain an organized practice, I schedule a single weekly (or biweekly) time slot for you. A minimum of 24 hours or one full business day's notice (whichever is greater) is required to cancel an appointment (example: to cancel a Monday 8:30 AM appointment, provide notice of the need to cancel no later than 8:30 AM on the Friday before).
Missed sessions are not billable to insurance & will be charged directly to you. When appointments are missed or canceled with less than the greater of 24 hours' or one full business day's notice, , you will be responsible for paying the equivalent of your insurance plan's allowable amount for the missed session. If you do not use insurance, the full session out-of-pocket fee is applied. Regarding a planning error or preventable miss, the policy holds. Missed Session or Late Cancellation Fees can be waived for emergency issues only. If a pattern of frequently canceling appointments with only 24 hours notice begins to emerge, I reserve the right to require a minimum of 48 hours or two full business days’ notice to avoid a late cancellation fee.
Termination Related to Missed Sessions:
If you miss 2 sessions in a row and I do not hear from you within two days after the second missed session, I will assume that you have terminated services with me and will release your scheduled appointment times. You may contact me about the possibility of resuming work with me after that, but I cannot guarantee I will have current availability or your previously held appointment time.
