Pre-Appt Packet

By providing the contacts above, I authorize BonPsy Wellness and its clinicians to reach out to them on my behalf to gather collateral information that might be helpful when conducting my evaluation. 

Insurance & Financial Responsibility Acknowledgment

I understand that Clarity California Psychological and BonPsy Wellness will make every effort to verify my insurance benefits and coverage. However, verification does not guarantee payment or coverage. I acknowledge that it is my responsibility to be aware of my own insurance benefits and coverage. I also agree to promptly notify my provider of any changes to my insurance during the course of testing. I understand that failure to do so may result in being personally responsible for part or all of the testing costs.

By signing below, you certify that you have read and understand the terms stated in this form. You indicate that you understand the scope of our services, session structure, fees, payment policy, insurance reimbursement, confidentiality, the nature of our practice, and contact information, and that you agree to abide by the terms stated above during the course of our relationship.

If prior authorization is required, BonPsy may need to provide information about your diagnosis, history, and treatment plan to your insurance company. Once this information is provided, it will be subject to the privacy policies of the insurance provider and is out of our control. Any co-payments and/or outstanding balances are your contractual responsibility and payable to BonPsy at the time of your visit for copays and immediately after your visit for any outstanding balance. It is your responsibility to inform BonPsy of any changes to your insurance during your evaluation process. If you do not notify us of any changes to your insurance in a timely manner, you understand that you are liable for any charges for services not covered by your insurance.

Payment Authorization & Financial Responsibility

By providing your payment information, you acknowledge and agree that a valid form of payment must be kept on file to schedule and hold all appointments. This card may be charged at any time for any outstanding balances on your account, including copays, deductibles, late cancellations, no-show fees, or unpaid services.

Please note that BonPsy Wellness is not a representative or agent of your insurance provider. If you have questions or concerns about denied claims, coverage, or reimbursement, we recommend contacting your insurance carrier directly using the number on the back of your insurance card.

We do not withhold medical records due to non-payment. However, we reserve the right to pause or discontinue services on open cases when a balance remains unpaid. We are committed to working with you to clarify any billing issues and encourage timely communication if you need assistance.

Patient Rights & Responsibilities

As a client at BonPsy Wellness, you have the right to:

Receive respectful and confidential care
Understand your diagnosis and treatment recommendations
Ask questions and participate in treatment decisions
Decline services at any time
You are responsible for:

Providing accurate and honest information
Arriving on time for scheduled appointments
Paying fees and balances in a timely manner
Communicating any changes in your needs or availability

Late Cancellation / No-Show Policy

Due to the extensive time commitment involved in psychological testing:

Missed testing day (without 48 hours notice): $250
Late cancellation (less than 48 hours notice): $100
These fees are not covered by insurance and will be billed directly to you.

By signing below, I acknowledge and accept the cancellation and no-show fees.

Payment Agreement Form

I understand that:

Insurance may not cover all services provided
I am financially responsible for all uncovered or denied charges, including but not limited to: materials fees, administrative charges, missed appointment fees, and non-clinical documentation
Payment is due before the final report is released
Accepted payment methods: credit/debit card, HSA/FSA, check, or online portal

Telehealth Consent (If Applicable)

If any portion of your intake, feedback, or therapy is conducted via telehealth:

Services may be provided via secure video conferencing platforms (e.g., Zoom, Doxy.me)
There are risks related to technology failures, unauthorized access, or interrupted privacy
In case of emergency or disconnection, we will contact you via phone as a backup
Please ensure you are in a private, quiet location during telehealth sessions.

I authorize BonPsy Wellness to contact the below -named providers to exchange relevant clinical information for care coordination.

Transparency Notice: Psychological Testing Materials Fee

At BonPsy Wellness, we are committed to being fully transparent—especially when it comes to any costs that may not be covered by insurance.

Due to the increasing expense of specialized testing materials—and the fact that most insurance companies, including yours, do not reimburse for these costs or adjust rates in line with inflation—we must implement a modest out-of-pocket fee in order to continue providing high-quality, in-network care.

In accordance with the No Surprises Act, we are notifying you in advance of a flat, non-refundable $150 materials fee. This fee supports:

Continued access to gold-standard, research-backed assessment tools
Our ability to serve patients within an affordable, in-network model
Avoiding the need to transition to an out-of-network or private-pay structure
We’ve intentionally kept this fee as low as possible—representing only a fraction of the actual cost—to balance accessibility with sustainability.

Next Steps:
To move forward with scheduling your psychological assessment:

You can pay the $150 materials fee via our secure payment link:
https://buy.stripe.com/7sY14n4Izd3J2NBcKe2wU00 or call our office to provide payment info.


Important Note:
We are unable to schedule your Psychoeducational Introductory Appointment until this payment is received.

If the transaction is declined or not submitted, you will receive one courtesy reminder. If no payment is received after that, your file will remain on hold until the balance is cleared.

Thank you for your understanding and partnership in supporting sustainable, high-quality care.

Before We Begin: A Quick Note About Who We Are

At CCPT, we want to be upfront with you about what makes our practice unique—and why that matters.

We are the only private psychological testing practice in both Massachusetts and California that is:

Independently owned by a single human—not a hospital system, private equity firm, or corporate board. Founded and led by a working mom of three, who’s been in the trenches of clinical care and parenthood for over a decade. Deeply committed to accepting as many insurance plans as possible—because we believe access to quality mental health care should never depend on your income We’re proud of these facts. But they come with a few realities we hope you'll understand:

What That Means for You

High demand: We receive over 400 evaluation requests every month.
Behind-the-scenes effort: Each case involves extensive work—scoring, analyzing data, writing detailed reports, and providing individualized feedback.
Staffing challenges: Great clinicians and psychometrists are rare. 

What You Can Count On
We promise to:

Deliver ethical, evidence-based, and affordable psychological care
Advocate for you and take your concerns seriously
Treat you as a whole person—not a number or diagnostic code

A Reality Check
If you’re seeking a white-glove, concierge-style experience—with instant availability, personal scheduling assistants, and cucumber water in the waiting room—we may not be the right fit. A fully private, out-of-network provider (charging $4,500–$8,500 out-of-pocket) might be a better match.

By choosing to work with us, you're embracing compassionate, high-quality care over perfection. You agree to extend us grace if things aren’t always seamless—and to share any frustrations directly with us (not Aunt Karen, Yelp, or Google reviews).

We're in this with you—and we’re honored to support your journey toward clarity.