Check In-Therapy
Hasan Ali LMSW
Type of Appointment:
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Online
In Office
Type Of Therapy:
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Individual Therapy
Couples Therapy
Group Therapy
Family Therapy
Child/Play Therapy
Patient Name
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First Name
Last Name
Patient Date of Birth
*
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Month
-
Day
Year
Reason for Visit:
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Would You Like to Avoid wait time at Front Desk? Pay and Schedule yourself!
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Yes
Will Do at Front Desk
Method of Payment:
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Credit Card
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Will Owe (Must remit payment within 30 days)
Psychiatry is a specialty copay found on your insurance card Copayments are due prior to your visit, please select one of the following options in the dropdown menu below.
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Therapy Intake-New Patient
$
200.00
Therapy Followup
$
185.00
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$
45.00
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55.00
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60.00
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65.00
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$
70.00
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$
80.00
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$
85.00
Copay
$
90.00
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