Practice Policy and Forms

New Patient Forms

New Patient Intake Form
Privacy & HIPAA Policy
Credit Card on File Policy
Telemedicine Consent Form

Practice Policy

  1. Forms and Patient Portal
  • All forms must be completed prior to scheduling an appointment.
  • All patients are encouraged to set up a patient portal account.
  1. Refill Requests
  • Refill requests must be submitted at least 72 business hours in advance.
  • Business hours: Monday–Friday, 9:00 AM–5:00 PM (phones are off during lunch from 12:00–1:00 PM).
  • I do not accept refill requests from pharmacies.
  • Please request refills through:
    • Patient Portal (preferred) or phone (leave detailed voicemail)
  • Refills will not be provided if:
    • The client hasn’t had a visit in the past 3–4 months, unless discussed with the provider.
    • The client has missed appointments or is non-compliant with treatment.
  1. Appointments & Follow-Ups
  • Clients are responsible for calling the office to schedule follow-up appointments if not done during the visit.
  • Appointments must be scheduled by patient portal (preferred) or by phone.
  • When scheduling telehealth appointments, you’ll receive a link via email and on your patient portal.
  1. Cancellations & No-Shows

Medication Management Appointments

A $75 no-show fee will be charged if:

    • You cancel without 24 business hours’ notice
    • You cancel or no-show between Friday at 5 PM and Monday at 9 AM

Therapy & New Patient Evaluations

  • A $125 no-show fee will be charged if:
    • You cancel without 48 business hours’ notice
    • You cancel or no-show between Friday at 5 PM and Monday at 9 AM

Discharge Policy

  • Patients may be discharged from treatment if they:
    • Accumulate 2 consecutive no-shows
    • Cancel frequently within a short period
    • Are non-compliant with care
    • Are disrespectful toward staff or providers
  1. Insurance, Deductibles & Co-Payments

Clients are responsible for:

    • Knowing their deductible amount before scheduling
    • Paying co-payments at the time of service
    • Providing updated insurance info within 30 days of the effective date
  • Clients with deductible plans are responsible for the full deductible amount until it is met.
  • Existing patients must keep a credit or debit card on file in our secure system.
  • New patients must put a credit or debit card on file in our secure system for appointment fees.
  • Fee for service patient’s cards will be charged the fee at time of appointment and superbill will be provided to the patient through email or patient portal for insurance reimbursement.
  • Fee for service rates are $250 for evaluation and $150 for follow up.
  1. Provider Timing
  • Please be aware that providers may run behind schedule. Allow extra time before and after your appointment to accommodate any delays.
  1. Paperwork Requests
  • Please allow 1 week for all paperwork to be completed.
  • A fee may apply for time spent completing documents.
  1. Pharmacy & Medication Availability
  • Clients are responsible for checking with alternate pharmacies if their usual location is out of stock.
  1. Emergency Services
  • This office does not offer a crisis line.
  • In case of emergency, please:
    • Call 911
    • Go to your nearest emergency room
    • Contact 211 for mental health support outside of office hours

💬 Final Note

We deeply appreciate your understanding and cooperation with these policies. They are designed to ensure:

  • Providers can deliver high-quality care
  • Operations run smoothly
  • Everyone’s time is respected