New Patients
Forms
Please fill out and bring the relevant forms when seeing your therapist for the first time, or if it's been a year since your last visit.
New Patient Forms for Adults (18 or older):
New Patient Forms for Children (17 or younger):
If you are insured by John Deere Health Care or United HealthCare, click below for an additional form. You may refuse to fill out this form without any loss of benefits but we are required to send it in so please bring it with you, blank or filled out.
Informed Consent for Telehealth (.docx)
Insurance
If you have insurance please call your insurance company before the appointment and ask:
- if a preauthorization is required,
- if you are meeting a deductable & what that means for you,
- the number of visits you are allowed, and
- if you have a copay.
As a service to our patients, we offer assistance with the preparation and submission of most health insurance claims. In most cases, however, our agreement concerning service is with you and not with your insurance company. You should assume you are responsible for payment of fees unless otherwise agreed upon. It is your responsibility to determine the extent to which your health insurance plan will cover the cost of evaluation and therapy. Some services are not reimbursed by health insurance. Further, many insurance plans require prior authorization for outpatient mental health services. It is your responsibility to determine the need for preauthorization and to obtain this if required by your plan. We advise patients with health insurance to be prepared to pay for services until we receive acknowledgement of your coverage. Some exceptions to this general policy exist. Please discuss this with your therapist or our staff if you believe exception supply in your case. Charges for missed appointments, disability forms, letters, and telephone calls cannot be submitted to your insurance carrier.
Appointments
Patients usually come to our office for weekly 45-50 minutes sessions. Some sessions (for example, psychological assessments) may last longer or occur more or less frequently. Your therapist will recommend the number and frequency of appointments to schedule at your first meeting. It is your responsibility to schedule appointments.
Confidentiality
Patients often express concern about the release of personal information. What you discussed in the session will be treated confidentially in accordance with the law and recognize professional standards. We take very seriously our responsibility to maintain your privacy. Exceptions to our policy of confidentiality may occur when the welfare of a child or dependent adult is in jeopardy or when a patient's behavior may be a threat to self or others.
Furthermore, most HMOs, EAPs, and PPOs require we send reports to them concerning diagnosis, stress factors, prognosis, and treatment goals. If you have any questions about these periodic updates please discuss this with your therapist.
Cancellations
Each appointment is a special time reserved for you. If you are unable to keep your appointment, we ask that you notify us at least 24 hours in advance in order that the time may be made available to someone else. If you do not give us adequate notice, you will be expected to pay for the missed appointments and such charges are not covered by health insurance. To cancel an appointment you may call us during normal office hours or leave a message on our answering machine after regular business hours and during weekends. Reminder calls are made two business days prior to your scheduled appointment. This is a courtesy call. It is your responsibility to know when your appointments are and to remember them.
Emergencies
At times patients experience difficulties between sessions and feel the need to speak to their therapist. Our policy is to encourage patients to call our office during normal office hours when they are having difficulty. We are often not available to take calls immediately but always try to return them as promptly as possible. After hours, one of our therapists is on call for emergencies only. We define emergencies as situations or difficulties that are potentially threatening to one's life or that of another person. Under such circumstances we encourage you to call our emergency number (383-1763) or go to the emergency room at Genesis West.
