CLIENT FORMS

	Client Forms           Client Application Financial Policy Service Agreement Service Agreement Appendixes HIPAA Privacy Notice Insurance Benefit Form Client Fact Sheet

• To the right are the required forms for the first appointment.
• Please print out each form separately.
• Each form needs to be completed and brought to the first session.
• HIPAA and Service Agreement. They have pertinent information regarding the practice's policies and procedures.
• For the HIPAA and Service Agreement we only need you to provide us with a copy of the signature page (for each form).
• When you come to the first session please bring a copy of your insurance card.
• Please be sure to print out and read the "Client Fact Sheet" which provides more information about our services and policies, before your first appointment.

PAYMENT INFORMATION

Payment is required at the time of service. For the first session the fee is $175.00 and for following sessions the fee is $150.00. However, if you are using your insurance your fee will most likely be discounted. Please discuss this with your therapist.

Your Centers for Family Change therapist accepts only cash or checks. We expect payment at time of service for co-pays, co-insurance and/or deductibles. We will bill your insurance for their portion of the fee.

PAYING BY CREDIT CARD

The Centers for Family Change is currently working to set up a cost effective way for you to pay your bill by credit card. Please talk to your therapist who can let you know when this option will be available and how you can use it.