Documents Required to begin Treatment

Thanks for clicking! I'm so excited that you are here!

Please read each item on this form carefully before answering each item.

This form is designed to help you decide if I might be a good fit for you so you can decide whether you should set up a consultation call with me.

What that means

I understand what it is like to make a decision that you are finally ready to start something, psych yourself up to do it, wait for that first call or appointment (hoping that it will be just what you've been looking for), only to learn that it won't work for you- and then you have to start all over again find! I'd really like you to avoid that. This form will cut through some of the logistics to see if I match your most basic requirements for a therapist (e.g., appointment availability, fees, etc.). For example, there’s no point in you wasting your time on a call if you are looking for someone in-network with your insurance or if my only appointment availability doesn’t work for your schedule. Instead, let’s get all of that out of the way now and if we line up in those areas, we’ll schedule a call to chat further so that you can share your needs, learn more about me and how I work, and decide if I am a good fit for you as a therapist.

Please acknowledge that you have read the statement above

"Yep, I read the above. Let's do this."

First name

Last name

Preferred Name

Preferred Pronouns

Date of Birth

Email address

Unfortunately, I am not seeing clients younger than 18 years old.

To find therapists who treat minors, please use the age search filter options in your insurance or preferred health provider directory. You may also contact the minor's pediatrician for a referral or visit the NJ Children's System of Care at the website (link below) for more options.

https://www.performcarenj.org/

Are you inquiring about yourself or someone else?

Myself Someone else

What is your relationship to the prospective client?

Prospective Client DOB

Name of Prospective Client

Unfortunately, I am not seeing clients younger than 18 years old.

https://www.performcarenj.org/

Please note that I only see clients ages 18 and older and only individuals who can legally consent to their own treatment. I must speak the the prospective client prior to setting up any formal appointment.

Preferred Contact Number

Type of Phone

Call Phone Home Landline Office

Is it OK to leave a message at this number if you don't pick up?

Yes No

Is it OK to text?

Yes No

Is it okay to email you at this address?

Yes

Fees and Payment Information

I am Out-of-Network with all commercial insurances, except for Optum/Oxford/United.
My fees are $200 for a $55 minute session. Payment is due at the time of service.
If you have commercial insurance* and would like to use your out-of-network benefits, I can provide you with a superbill so that you can submit for reimbursement. It is your responsibility to submit for reimbursement and to familiarize yourself with whether your insurance will reimburse your services and, if so, how much they will reimburse.
I utilize Thrizer, a service which works with some insurance companies to make out-of-network benefits easier for clients to access. While Thrizer does not change the amount you may be reimburse, it will handle the reimbursement paperwork for you and will also pre-pay the portion of the service that the insurance will reimburse so that you do not have to wait for reimbursement (to learn more and find out if Thrizer works with your insurance, please visit www.thrizer.com).

*Please note that I am not a Medicare proivider. If you have Medicare benefits, you will not be able to submit for reimbursement, even if you have a commercial plan that allows you to see out-of-network Medicare providers. Also, I am unable to see Medicaid clients as an out-of-network provider.

Do you have health insurance that you plan on using (either In-Network or Out-of-Network)? If you plan on requesting your insurance carrier to reimburse you for your payments, please select "Yes

Yes, I have Optum, United, or Oxford I have a different insurance and plan to submit for out-of-network reimbursement I do not plan to use insurance and will not seek reimbursement)

Insurance

Horizon/BCBS Aetna Cigna Other

Specify Other Insurance

Please note that I am an out-of-network provider with your insurance carrier. It is possible that my services may be covered in full or in part by your insurance carrier. However, you would be responsible for paying my full fee at the time of service and for arranging to be reimbursed by your insurance carrier.

"Got it!"

Please note that I am not a Medicare Provider. I can see you for therapy, however, you will be responsible for the fees and cannot legally submit for reimbursement, even if you have a commercial Medicare plan that allows you to see out-of-network providers (they must still be Medicare providers).

"I understand"

Unfortunately, I am not a Medicaid provider and am not able to see you for therapy. State law prohibits Medicaid clients from paying out-of-pocket for services.

"Bummer! Thanks for letting me know."

Message (optional)

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