GENERAL INFORMATION

Before or at the time of your initial visit you will be asked to complete some routine forms. These forms consist of the Assessment Questionnaire, this Patient Information Sheet, HIPAA Regulations, Privacy of Information Policies and standard measures of symptoms when appropriate. If we have remote sessions please also complete the Teletherapy Consent Form.

In general, the number of visits you will require will depend on the type of problem(s) you are experiencing, the recommendations made by your therapist and the time you spend outside of the therapy sessions working on the problem and following through with recommendations.

APPOINTMENTS

Appointments will be scheduled at a time acceptable to both the patient and the therapist. Initial assessment appointments (CPT code 90791) last 50-55 minutes and regular sessions last either 45 minutes (CPT code 90834) or 55 minutes (CPT code 90837).

FEES - Federal Truth in Lending Disclosure Statement for Professional Services

Part One - Fees for Professional Services

I (we) agree to pay Dr. Sarah Allen Inc., a rate of $ 275 for the assessment and either $ 200 per 45 minutes session or $245 for 55 minutes session for counselling. Payment is due at the time of the session by cash, check or credit card. If you wish to pay by credit card please download and complete the Credit Card Payment Authorization Form.

Part Two - Cancellation Policy

There is a 24 hours notice cancellation policy. If you cancel a scheduled appointment with less than 24 hours notice, I typically cannot use this time for another client and you will be charged a cancellation fee.

Less than 24 hours $200/245 depending on the length of planned appointment.

Missed appointments without any prior notice $200/$245 depending on length of planned appointment.

Cancellation due to overnight Illness - Please let me know 7.30am the day of the appointment. The cancellation fee is $0 if we can reschedule. After 7.30am $200/$245 depending on length of planned appointment.

In the case of illness, I always try to reschedule for later in the week if I have a slot available, or do a telephone/video call instead of meeting in person. Please call or text me before 7.30am on the day of the appointment, to notify of serious overnight illness. It is okay to send me a text in the middle of the night, it won't disturb me.

 

Part Three - Clients using Medical Insurance

It is the client’s responsibility to contact the insurance company to find out their insurance benefits. Dr. Sarah Allen Inc. will provide you with a statement that contains all the relevant information about the session and your diagnosis and treatment codes. You will then be able to submit the statement to your insurance company for reimbursement. 

An insurance company may not pay for services that they consider to be non-efficacious, not medically or therapeutically necessary, or ineligible (not covered by your policy, or the policy has expired or is not in effect for you or other people receiving services). In the event that your benefit was misquoted by your insurance company, it is still your responsibility to pay your balance with us.

Part Four - Medical/FMLA/Legal Letters

Dr. Allen does not write medical or legal letters or forms for clients unless they are established clients that have been under her care for more than 3 months.

I hereby certify that I have read and agree to the conditions and have read the Federal Truth in Lending Disclosure Statement for Professional Services. I have read this patient information sheet and understand the requirements and rules of this office. I agree to the terms there in and give my consent to the evaluation / treatment process with Dr. Sarah Allen.